Heart Ambassadors for Connected Hypertension Care

In São Paulo, ¼ of the population has high blood pressure (BP). In the public health system, we find low engagement to primary care services and insufficient community outreach. Public Primary Care Clinics (PCCs) strive to bring the target population to their services to ensure prevention, treatment and control of hypertension. The Heart Ambassadors (HA): PCCs representatives empowered to lead prevention, screening and referral activities focused on the hypertensive population and to connect community actors for strategic actions in their territories. That includes leveraging the city's official app for appointment scheduling and also registering and bringing priority users to PCCs through SMS/chatbot message engaging system. The app is already operating, and complementing this service with the messaging system will catalyze scale. Combining empowered health agents with digital technologies will lead to higher rates of screening, referral, treatment and BP control, reducing risks and deaths related to cardiovascular diseases.

According to the World Health Organization (WHO), Cardiovascular Diseases (CVDs) are the  first cause of death globally. An estimated 17.9 million people died from CVDs in 2016, representing 31% of all global deaths. In Brazil, CVDs are also the main cause of deaths and there are approximately 36 million people with hypertension with estimated 350 thousand deaths/year. National data estimate that the prevalence of referred hypertension is 22.7% among Brazilian adults (2015). São Paulo has a prevalence of 23,2% hypertensives, the region served today by the program has a population of 454,134 active users in 2018, among those users, 113,511 (25%) are estimated as hypertensive, but only 34,725 (30.6%) are identified.

In underserved communities, families face multiple barriers to active health engagement. Despite of the multitude of responsibility, PCCs operate with limited resources, struggling to ensure health promotion, prevention and treatment.

The demand for PCCs for prevention is low, and in the case of hypertensive population, there is often also a late search for treatment. Population often faces barriers on the appointment scheduling to ensure diagnosis or treatment.

Itaquera is a heterogeneous neighbourhood with high income areas next to low income urban occupations and communities. It has approximately 550,000 people, a HDI of 0,803 and progressive presence of immigrants. 

The project has listened more than 200 people among clinic managers, doctors, nurses, pharmacists, nursing technicians, community health agents, community and others. In Itaquera territory, there are over 454,134 active users of the public health system, representing 78% of the region's inhabitants, and estimated 113,511 hypertensive users according to ISA Capital, City Hall Health Survey. However, there is a low population engagement with the Primary Care Clinics, essential for prevention and health promotion. 

In this regard, defining Primary Care Clinics as a care coordinator, in a ecosystem that can be structured with the Heart Ambassadors dialog, the solutions aim to expand and facilitate access to PCC's services focusing on hypertension prevention, screening and treatment. Heart Ambassadors is the linkage of a set of solutions that will favor the consultations scheduling via app, support self-care through SMS and Chatbot systems and bolster health teams work through social networks.

Heart Ambassadors are representatives of the PCCs that lead initiatives in prevention, screening and referral of the hypertensive or at-risk population, in partnership with community organizations, companies, soccer teams and others. They are defined by the clinic's management and have specific skills to increase the reach and effectiveness of primary care services around hypertension.

The regional health department defines an annual training schedule on the initiatives and tools that fit the profile of the Ambassadors. Throughout the year, missions are also defined, such as carrying out joint efforts to screen and refer the population on campaigns of National and World Hypertension Days.

Among the actions carried out in this model, we highlight outreach screening events with BP measurement and free health orientation focusing on the risk factors for hypertension, which include:

1) Service for scheduling appointments via mobile app: once downloaded at the event, the person can immediately schedule the appointment at the closest clinic to their residence. Solution already offered by the São Paulo Municipal Health Department, promoted within the health clinics and that can be scaled by the work of the Ambassadors in the territory.

2) Data record, including mobile numbers of people with altered BP to send alerts to visit the PCC for an appointment or specific treatment. People who express interest receive a message a few days after having the pressure measured in the event, with a reminder to schedule an appointment, and from there an interactive chat starts. The system requests information from the user and provides information pertinent to their profile, or responds to questions from the interactions in an automated way, and can be easily replicated.

The events are held with partner organizations of the urban territory and public spaces, such as shopping malls, public transportation stations, markets, squares, parks, schools, companies, religious institutions, among others. The solution is particularly suited to urban and slum areas as the bonds between population and public services in a megacity as São Paulo tends to be weak, compromising sustainable engagement from prevention to treatment. 

From the data recorded, the clinics teams can monitor the users tracked in the event, and even contact those who presented greater risk at the time of BP measurement, supporting the scheduling of appointments.

Ambassadors from different clinics in the same region exchange mission experiences and results through social networking platforms such as WhatsApp messages, enhancing engagement and collaboration among them.

The solution has been developed based on design thinking principles, community need assessment and inclusion of the primary beneficiary of public services in the development of the solution.

The Heart Ambassadors program is innovative not only because its human centered approach methodology, but mainly because it links the training and empowering of public agents with the use of existing technologies to scale the capacity of primary care clinics to reach and engage target population, promote health prevention, screening, referral, and treatment of hypertension, aiming to reduce risks and deaths related to cardiovascular diseases.

The creation of the role of the Heart Ambassador was a result from the local diagnosis and co-creation efforts conducted with the PCCs teams in Itaquera. It was based on the experience of members of the clinics - whether staff or community council - who were already leading successful initiatives in prevention activities for groups attending the clinics and the surrounding community. Their common skills and attributions led to the creation of the role through a training program for such agents in 6 pilot clinics, and then in 24 clinics in an expansion phase.

The solution adds currently available digital service (scheduling app) and existing technology (SMS/chatbot) to the work of empowered agents, for more impact and scale. The scheduling app is underused and has a great impact potential. And the text messages system can approach and engage millions of people that are currently not treating their health conditions.

The solution is a new process within the municipal health services, specifically dedicated to hypertension care. It relies on three main core technologies:

Automated SMS/chatbot messaging service: an existing technology based on a predefined content and exchange flow according to programmed questions and answers. After outreach screening events led by Heart Ambassadors (HA), people who expressed interest receive a text message a few days after having the pressure measured in the event, with a reminder to schedule an appointment, and then an interactive chat starts. The system requests information from the user and provides information according to their profile, or responds to questions from the interactions in an automated way. Chatbots use artificial intelligence to orient the interaction towards prevention, referral, diagnosis, treatment and control goals, depending on each individual case. For scale, this technology will be scaled under Creative Commons licences.  

"Easy-Scheduling" mobile app for appointments in the public PCC closest to the users residences. The citizen can see available spots on the PCCs schedule and choose the one more convenient, with no need to go to the PCC in person to schedule. Although the app is currently available for download, HA are simplifying the unblocking process, offering this "service" during outreach events and other public facilities. 

Social networks (Whatsapp) - this technology is key empowering HA groups, building a network of change agents and stimulating collaboration among teams of different clinics. Since the pilot phase, the HA have been actively sharing achievements and creating solid connections with peers.

Project Overview: Reduce morbidity and mortality rates due to diseases related to hypertension in São Paulo

Mission: To develop and implement a replicable, scalable and sustainable model to improve the screening, diagnosis, treatment and control of hypertension (HTN) in São Paulo city.

Goals:

• Provide mechanisms to qualify the line of integral care of people with hypertension

• Develop and implement a management model for the care of the hypertensive population

• Instrumentalize the ecosystem for permanent health education

• Strengthen the role of PCCs as coordinator of the health ecosystem in its territory

The HA contribute to increasing the screening and referral of people with altered pressure and/or hypertension to the reference PCCs for proper diagnosis, treatment and control; and strengthening of the role of the PCCs as coordinator of a health ecosystem. 

So far, over 60 HA from 24 PCCs were trained in Itaquera. They have created, led and/or supported over 20 new activities within their PCCs territories. Over 6,000 people were screened in 17 outreach events. Over 5,000 text messages were sent to screened people (1,500 numbers database) and the scheduling app has been downloaded and used during outreach events. From 2018 to 2019, the number of appointments registered as HTN patients in the official records increased 23,6% in the 6 pilot PCCs and 19.79% in the other 18 PCCs - where the project expanded only in 2019 -, while the average increase in the control neighborhood not involved in the project was around 3,78%.

São Paulo has a estimated population of more than 12 million inhabitants and a prevalence of 23,2% hypertensives representing more than 2 million people. The Itaquera region, served today by the program, has a population of 454,134 active users in 2018, among those users, over 113,000 (around 25%) are estimated as hypertensive, but only 34,725 (30.6%) are properly identified/registered. The program is already implemented in 24 Public Primary Care Clinics, and the expansion plan aims to expand the project to another neighbourhood with an estimated population of 400,000 inhabitants in one year, and all São Paulo city in the next five years.

1 year

• Consolidate the work in the 24 PPCs where the program is already installed.

• Extend the program to another region of the city, totalizing around 50 PCCs and covering almost 1 million people

5 years

• Train 900 Ambassadors from the 460 PCCs of São Paulo city (2 per PCC)

• 100% of the 460 São Paulo PCCs with the solution implemented.

• Formalization/consolidation of the solution as a public policy.

• Replication and implementation of the project at scale, linked to a department inside the municipal health secretary, that leads the solution, giving sustainability to the project.

The main barriers to accomplish the goals are: 1. Financial: the PCCs have limited resources for training and engagement promotion strategies; 2. Technical: the focus on NCDs such as HTN is sometimes faded by the urgency of NTDs campaigns; 3. Political: elections period may bring new political groups into the public administration, thus changing priorities; 4. Cultural: low engagement of health agents and citizens

1. Financial: model of low cost activities, distance trainings and use of resources already planned on annual budget for similar solutions;

2. Technical: use of evidence based solutions, managing the data collected by the HA and other health professionals as a way to favor planning and execution of actions that will reduce urgencies and bring more stability to the health teams;

3. Political: engage key public agents that can take the role of policy entrepreneurs and owners of the solution; create a guide-book (online and offline) with learnings and step-by-step actions to favor the implementation and replication of the program, besides bringing evidences of effectiveness and positive impact of the solution on key social/health indicators;

4. Cultural: incorporation of the trainings in the official calendar for the public health agents, recognition of their efforts (gamification or rewards); for the citizens, use of simple and intelligible language and storytelling, adapting to different target population (elderly, adults, youth…), besides the use of different communication channels (SMS, whatsapp, advertising and events in public transport stations…) and artificial intelligence.

Our team: at Tellus agency we dedicate 11 full-time employees to this project;

Public Health System employees and community council members focused on this solution: 60 individuals

The team dedicated to the project at Tellus has a diverse set of skills, backgrounds and experiences that are key to designing, implementing and scaling innovative public services. 

Main skills: mastery of innovative government solution development techniques, understanding of the policy context, group engagement/empowerment tools and techniques

Main backgrounds: graphic / strategic / service / human centered design, health, consulting, marketing, corporate sustainability and social investment, public / business administration, architecture, international relations, communications

Experiences: design and implementation of services and public policies in health, education, social services in urban areas in partnership with local governments and different stakeholders.

Tellus is leading the implementation of the solution as part of the Better Hearts Better Cities initiative sponsored by Novartis Foundation in Sao Paulo, in partnership with the Health Department of the City of São Paulo and other national and international organizations. 

Associação Samaritano is a strategic partner and also sponsoring the initiative. 

American Heart Association (AHA), Brazilian Society of Hypertension (SBH), Society of Cardiology of the State of São Paulo (SOCESP) are technical partners 

IQVIA is responsible for impact assessment.  

For the solution specifically, the Municipal Health Department is supporting the engagement of Health Ambassadors and their training as well as in the co-design of the sustainable model.

The solution's main customers are the Heart Ambassadors of Primary Care Clinics who are provided with training and technology to improve local health indicators. 

The beneficiaries are the local population of around 500,000 people served by the PCCs and the services led or supported by the Heart Ambassadors. 

Revenues are currently enabled by the project's private sponsors. The project includes the design of a financial sustainable model to ensure the solution is part of municipal budget for training of Heart Ambassadors and deployment of technology. 

Products and services: Training of Primary Care Clinic's representatives - the Heart Ambassadors - based on strategies to improve prevention, screening and referral of hypertensive population or population with elevated blood pressure. These strategies include new and existing processes and tools, including orientation on how to use technology to support remote communications and engagement of the population: 

• A guide to develop screening / referral events with available tools

• SMS and chatbot provided to Primary Care Clinics, in order to support the follow-up of screening and referral efforts

• Scheduling app - Agenda Fácil 

• Social networks (Whatsapp)

Channels:

The City's Hall Health Department and its local administrations would be responsible for providing training and supporting their continuous online engagement, as well as to ensure access, availability and maintenance of the technologies (SMS/chatbot, Agenda Fácil app)

The solution's development is currently supported by Better Hearts Better Cities sponsors, and will last until the end of 2020. 

The path to financial sustainability is part of the project's expansion and sustainability strategy, which considers that the solution will be financed from the municipal annual public budget. This implies a minimal additional allocation of resources for the solution to be sustainable in the long term, the analysis of existing public policies and programs, and opportunities in the current public health framework for the solution to be incorporated.

What makes it possible is that annual budget of the city hall already foresees allocation of resources in goals and actions connected this solution is targeting. 

Besides that, training the municipal technology responsible areas (CETIC, PRODAM) will be mainly studied and engaged in the creation of models that respond to the demands of health of the city hall, enhancing existing resources.

We believe that Solve support can leverage our technological development and refine our sustainability model, making our solution more effective among the target population - either the health department and PCCs staff and citizens of São Paulo city. Moreover, Solve could connect us with other initiatives that addressed similar problems in other cities and countries, gathering a benchmark and evidence based experiences.

As our solution aims the use of artificial intelligence and bigdata do inform policy makers and PPCs staff on how to deliver more effective health services and actions, having technical expertise from such partners will take the solution to another stage.

We would like to partner with MIT in the development of the technology and its applications in the project's context.  

Also, we would like to connect with social entrepreneurs in the health and wellbeing sector, especially those dealing with public services and scaling up of solutions