The convergence of high rates of diabetes and hypertension and barriers due to social drivers of health makes chronic illness management more challenging for medically underserved populations. Interventions using remote patient monitoring, health coaching, and telehealth separately have yielded positive results. However, community health centers (CHCs) and rural providers who care for the individuals in underserved communities struggle to implement these evidence-based programs in ways that are feasible and sustainable.  

ACTIVATE is a model for digital health that fulfills the needs of underserved communities dealing with chronic illness developed through a successful partnership between the University of California Berkeley/CITRIS and the MITRE Corporation. The program leverages a unique co-design approach to provide a comprehensive virtual care solution that helps health centers overcome common barriers to digital health implementation. ACTIVATE provides technology to patients and improves efficiency for care management to increase provider capacity to deliver care to vulnerable populations, impacting the largest scale healthcare challenges

The ACTIVATE platform combines technology and digital health pathway care models that can be adapted to support different chronic conditions. 

The HIPAA-compliant platform shares data from FDA-approved remote patient monitoring devices provided to the patient with an ACTIVATE Program Manager that integrates with the EHR. Patients can view their data through the MyACTIVATE mobile app and are guided through the digital health pathway by a health coach, who facilitates health goal setting, education, and care coordination. 

Optimizing Technology

Paramount to the ACTIVATE approach are carefully designed program implementation services and features that optimize the use of technology and promote success for health centers and their patients:

• Co-design and detailed program planning in collaboration with the ACTIVATE team.

• Implementation Toolkit to support detailed planning for tailored program implementation with the ACTIVATE team.

• Digital Health Pathway models for care coordination that incorporate digital navigation, patient education, care team huddles, and health coaching. 

• Key program support roles include a health coach for care coordination, a digital navigator to improve digital literacy, and a program coordinator for operation management. 

• Program evaluation, and improvement support provided by the ACTIVATE team to analyze programmatic and health outcomes. 

Outcomes & Impact

The ACTIVATE platform is currently implemented at four community health centers in the Central Valley region of California.  ACTIVATE has demonstrated meaningful outcomes in these community health centers: An average of 3.5 point reduction in hemoglobin A1c, 20 point reduction in systolic blood pressure, and 5 point reduction in diastolic. Thus far, these implementations demonstrate how a co-designed solution for remote patient monitoring and chronic illness management delivered by community health centers can overcome digital divide barriers.