Stroke prevention for the patients your ED keeps seeing.
A remote blood-pressure monitoring program built for uninsured and under-insured Californians at $10–17/month — designed to live inside your Epic environment, not parallel to it.
The problem in your county
≈ 47%
of US adults have hypertension
CDC, 2023. Roughly half are uncontrolled.
≈ $0
of CMS RPM reimbursement
for uninsured patients. RPM CPT codes 99453/99454/99457 don't apply.
3–5×
ED visit cost of an avoidable stroke
vs. a year of consistent BP management.
Existing RPM platforms cost $35–80/patient/month and are designed around insurance billing. They don't work for the cash-pay, uninsured population that disproportionately ends up in your emergency department with preventable cerebrovascular and cardiovascular events.
The care model
Direct primary care, mission-first
Patient pays $10–17/month. That covers one annual visit, baseline labs, generic antihypertensives from a mail-order pharmacy, and continuous async monitoring through the app. No insurance billing, no per-claim overhead.
Patient logs BP, app does triage
Patient enters readings on their phone (any drugstore cuff works). The app runs the escalation protocol: lifestyle nudge → reinforcement → med titration suggestion → clinician review. Only the patients who need a human get one.
Clinician sees a triaged queue
No more chart-trawling. The clinician opens the app and sees 'these 4 patients need you today, here's why, here's the protocol's suggested next step.' They act in Epic — chart, order, message — same as any other patient.
Bilingual from day one
Every patient-facing screen and message is in English and Spanish. The hardest-to-reach uncontrolled-HTN populations in the Central Valley and Sacramento region are predominantly Spanish-preferred.
What we're asking from the hospital
The clinical workflow already works. The unsolved piece is infrastructure: where does the record live, and who carries the BAA? The cleanest answer is Epic Community Connect.
A Community Connect seat
- •Patient charting happens in your Epic, under your BAA
- •BPs flow in as FHIR Observations (LOINC 85354-9)
- •MyChart handles patient identity, consent, and messaging
- •Care Everywhere keeps the parent hospital looped in for shared patients
Shared governance, not vendor sprawl
- •No new vendor for the hospital to credential
- •App is a thin client against your Epic — no parallel EMR
- •Patient data never leaves your hosted environment
- •Pilot starts with 20–50 patients; scales only if outcomes justify
What the hospital gets back
- Community benefit reporting — uncompensated care to uninsured patients qualifies under IRS 990 Schedule H and California SB 697.
- ED diversion — every preventable hypertensive emergency avoided is a 4-digit cost saved.
- Quality measure improvement — CBP (Controlling High Blood Pressure) is an HEDIS / CMS Star measure the hospital's value-based contracts already track.
- Referral pipeline — patients who stabilize and gain coverage convert to attributed lives.
- Publishable outcomes — a prospective cohort of uninsured patients managed via async DPC is a publishable design at JAMA Network Open / JABFM scale.
Try the prototype
Open either side. All data is synthetic; nothing leaves your browser. Both demos are pre-loaded with 10 patients across every escalation state — controlled, escalating, non-adherent, newly enrolled, and recovered.