North State Pilot Program
Phase 1 (6–9 months) completes the app; UC Davis reviews the protocols; a separate independent organization reviews it with simulated patients; and an engineering firm receives the codebase for security hardening. Phase 2 (3–6 months) is a supervised per-clinic pilot. Each participating site—starting with Enloe Medical Center for the uninsured track and local Glenn County clinics for insured patients—enrolls roughly 15 patients.
A core design goal is keeping the burden on clinic staff low. Automated triage, bilingual patient education, and protocol-driven titration reminders handle the routine work so clinicians and MAs only engage when the app flags a patient who needs a human decision.
Two phases: validate the platform, then pilot it
Splitting the project keeps clinical risk and partner burden low. Nothing touches a patient until the algorithms have external clinical sign-off and the codebase has been independently hardened.
Phase 1
6–9 monthsBuilding a safe, validated RPM platform
Clinical workflow refinement
Finish the clinician queue, titration, documentation, and patient education flows; refine them against real clinical workflow feedback.
Protocol review with UC Davis
UC Davis reviews the protocol — triage bands, escalation rules, titration ladder — for consistency with national guidelines and provides written sign-off. Independent platform validation follows after sign-off.
Independent technical verification and security hardening
A separate software engineering firm independently verifies the technical implementation against the reviewed protocol and hardens the codebase — stability, structural refactors, and any security gaps — before any patient data flows.
Phase 2
3–6 monthsSupervised pilot with Enloe and local clinics
Partner: Enloe Medical Center
Enloe provides the clinical anchor — escalation pathway, telehealth follow-up, and the identity crosswalk held inside its own systems.
~15 patients per clinic
Every participating site runs its own ~15-patient cohort — Enloe for the uninsured track and local Glenn County clinics for insured patients — so the pilot surfaces real workflow friction at each site while staying small enough to support closely.
TCCAP community health workers
CHWs onboard patients, assist with registration, maintain the identity ↔ pseudo-ID crosswalk, and deliver device education in English and Spanish.
What the 3–6 month pilot is designed to answer
The pilot is a learning instrument, not a scale test. Fifteen patients per clinic is enough to surface real workflow friction and validate staff-time savings without burying problems in volume.
Workflow and usability
Does the loop actually work for a patient with a cuff and for the clinician reviewing the queue? Where do people get stuck, drop off, or need a human?
Integration with Enloe
How cleanly does the de-identified app sit alongside Enloe's systems and processes — crosswalk handling, documentation copy-out, escalation, and follow-up scheduling?
True cost per uninsured patient
Measured, not estimated: CHW onboarding time, device, labs, medications, clinician review, and platform overhead for one uninsured patient on remote monitoring.
Gaps and needed improvements
A written punch list of what has to change before expansion — clinical, technical, and operational — carried straight into the next funding request.
Staff time saved at the clinic
How much routine between-visit work — triage calls, education repeats, titration reminders — is shifted from clinic staff to the app's automated protocol, and whether that holds across varied patient panels.
Role clarity and scalability
Can MAs and CHWs handle enrollment, device setup, and protocol-driven tasks while licensed clinicians stay focused only on clinical decisions?
Why the blood-pressure target matters. The reduction the program aims for exceeds the clinically validated threshold established in landmark meta-analyses such as the Blood Pressure Lowering Treatment Trialists' Collaboration, where a 5 mmHg drop in systolic pressure reduces overall cardiovascular risk by roughly 10% and stroke by roughly 14%. Achieving that among hard-to-reach, uninsured, and tribal populations addresses rural health disparities directly while mitigating high-cost acute events like myocardial infarction and stroke.
Who does what. Existing clinic medical assistants and TCCAP community health workers conduct enrollment, form completion, and protocol-driven tasks; licensed clinicians are reserved strictly for clinical decisions. Software engineering cost is minimized with AI-assisted code generation as a developer tool — with zero AI used in clinical decision-making.
The hub-and-spoke model
Enloe as the clinical hub. North State Prevention's async monitoring app and Glenn County safety-net clinics as the spokes. Patients flow in from both directions; algorithmic BP control is delivered where the patient already is.
North State Prevention app
Async BP monitoring, MI-based education, protocol-driven titration alerts for the uninsured cohort.
Enloe Health (hub)
Clinical anchor. Care coordination, telehealth follow-up, outcome tracking, escalation for complex cases.
Glenn County clinics
Safety-net clinics, RHCs, and Public Health. Warm handoff of uninsured HTN patients, back-referral once controlled or insured.
Patients: uninsured and underinsured adults with hypertension in Glenn County. Handoff is voluntary and consent-driven. No PHI flows between partners at all: the clinic keeps the alias-to-patient crosswalk in its EMR, and North State Prevention holds only coded readings.
Built as a regional partnership
No single organization has the clinical capacity, community reach, technology, and resources required to address Glenn County's hypertension-access gap alone. The partnership combines public health leadership, primary and hospital-based clinical care, Community Health Workers, technology development, academic expertise, and health-plan collaboration to create a coordinated RPM model serving both insured and uninsured residents.
Glenn County Public Health
Project lead
Provides program governance, clinical model development, project oversight, and coordination among partners. As a Public Health employee, Dr. Garrison leads development and implementation of the RPM application with support from digital transformation consultant John Meyer; an IT consultant and legal counsel support software testing, cybersecurity, privacy, data governance, and regulatory compliance.
Tri Counties Community Action Partnership (TCCAP)
Community implementation partner
Coordinates day-to-day implementation, recruitment, enrollment, and CHW services. Community Health Workers conduct outreach, assist with eligibility and enrollment, provide device training and education, troubleshoot technology, reinforce adherence, and help participants overcome transportation, health-literacy, and other access barriers.
Participating primary-care clinics
Clinical pathway for insured patients
Glenn Family Practice, Family Care Clinic, Orland First Care, Northern Valley Indian Health, and Orland Medical Clinic provide the clinical pathway for insured patients, each enrolling roughly 15 patients. Medical assistants and clinic staff support enrollment and integration of RPM into existing workflows, while clinicians review actionable readings, manage medications and laboratory follow-up, and document care. One additional local clinic is in discussion and expected to join.
Northern Valley Indian Health
Tribal access pathway
Provides an important pathway to reach residents on the reservation and has designated a physician assistant to help oversee the project, with particular interest in improving hypertension control among patients who have been difficult to manage.
Enloe Medical Center
Clinical hub for the uninsured track
Serves as the clinical hub for the uninsured track, providing remote clinical oversight and telehealth-based care with TCCAP CHW support. This hub-and-spoke approach allows uninsured residents to receive coordinated hypertension management without requiring routine travel outside the county for every interaction.
UC Davis
Clinical consultation
Provides clinical consultation regarding the application's decision logic and evidence-based hypertension pathways.
Partnership HealthPlan of California
Coverage transition support
Collaborates on referrals and available information regarding members losing Medi-Cal coverage, helping reduce gaps in care during transitions in coverage.
A coordinated pathway
Together, these partners create a coordinated pathway linking public health, primary care, hospital-based care, CHWs, telehealth, technology, and community resources. The collaboration is designed to improve the TCM hypertension-control metric by increasing engagement, identifying uncontrolled blood pressure earlier, supporting timely treatment and laboratory follow-up, and addressing barriers that contribute to poor control.
The partnership will also generate the operational and cost information needed to determine whether this model can be sustained beyond the grant and replicated in other rural communities.
The technical workflow that makes the hub-and-spoke work
Every reading walks the same four-layer path — patient device → BAA-covered vendor cloud → North State Prevention protocol engine → clinical workflow. Trust boundaries are either signed by a BAA or verified in code; no anonymous data hops.
Data source
Patient + device
- Omron Bluetooth BP cuff sends readings to North State Prevention via smartphone
- North State Prevention App sends notifications, education, support to patient's smartphone
Trust boundary · BAA
Vendor cloud + ingest
- Omron Partner API (OAuth, cloud-to-cloud)
- Bandwidth Messaging (HIPAA-eligible)
- HMAC-signed webhooks → /api/public/*
Protocol engine
North State Prevention platform
- Triage (AHA bands) + escalation rules
- UC Way titration + KDIGO carve-outs
- Postgres + RLS + append-only audit log
Human decisions
Clinical workflow
- Triaged clinician queue + SOAP draft
- Outreach queue (SMS + call scripts)
- Patient nudge in-app (MI-based)
BAA with every hop that touches PHI
Omron (device cloud), Bandwidth (SMS), and the hosting provider all sign BAAs. No PHI in vendor logs.
Signed device webhooks
Every reading arrives with an HMAC signature verified before storage — no anonymous writes.
Row-level security + audit log
Postgres RLS scopes every read to a single patient's care team. Append-only audit_events records every access.
Fixed-menu SMS, no PHI in body
Outbound texts never carry BP numbers or diagnoses. Replies use reply codes (1=well, 2=dizzy, 3=chest pain).
Two cost structures: clinic-paid for insured, safety-net for uninsured
North State Prevention is free to patients. Participating clinics pay a modest per-patient fee for the application and RPM infrastructure; uninsured patients are carried by a separate safety-net structure with TCCAP's discounted pharmacy, laboratory, and telehealth rates. Every figure below is an anticipated cost the pilot is designed to measure.
Insured / Medicare
~$5 / patient / mo
Charged to the participating clinic, not the patient. For patients meeting applicable Medicare RPM requirements, clinics may receive about $52.11/month in 2026 reimbursement based on two required readings per month — the pathway that lets a clinic support the technology fee out of routine care. The pilot tests whether $5 actually covers technology and administrative cost.
Uninsured (post-grant)
~$15 – $20 / mo
For a stable patient on a single combination medication, including medication, annual laboratory cost, and roughly $5/month equivalent for an annual $60 telehealth visit. Patients requiring additional medications or greater clinical support cost more; the pilot establishes the real baseline.
| Uninsured patient — item | Cost | Notes |
|---|---|---|
| Blood-pressure monitor (one-time) | ~$60 | Grant-funded during the pilot; patient-purchased afterward |
| Annual telehealth provider visit | $60/yr (~$5/mo) | TCCAP-facilitated telehealth |
| Annual lab panel (CMP + UACR) | $30/yr (~$2.50/mo) | Discounted Quest rates + draw/supply via TCCAP partnership |
| Single-pill combination medication | ~$40/yr (~$3.50/mo) | 90-day fills at TCCAP discounted pharmacy rates |
| + Additional agent (Step 3a/3b add-on, if needed) | +$88/yr (~$7.50/mo) | Same mail pharmacy |
| CHW enrollment, device setup, and education | TBD | Heaviest at enrollment, falls substantially once a patient is stable — a key pilot measurement |
Existing clinic medical assistants and TCCAP community health workers conduct enrollment, form completion, and protocol-driven tasks; licensed clinicians are reserved strictly for clinical decisions. That division is what keeps the per-patient cost in the range above.
After the pilot: a dual-track model for Glenn County
Expansion splits along the two populations that need different front doors. Both run the same protocol engine and the same de-identified data posture.
Track A — Uninsured, via hospital partnership
The Enloe model, scaled: uninsured and under-insured adults enrolled through hospital and community partners, with community health workers holding onboarding and the identity crosswalk. Funded by grant support plus the low-cost direct-access subscription.
Track B — Clinic-based, Glenn County
Glenn County clinics and RHCs enroll their own insured and Medicare panels, with medical assistants handling registration, device education, and day-to-day monitoring support. Clinics bill RPM device codes directly.
Sustainability after grant funding
The long-term model rests on four things: modest recurring clinic revenue (~$5 per enrolled patient per month, supportable by 2026 Medicare RPM reimbursement of about $52.11/month for qualifying patients), very low technology cost, decreasing community health worker intensity as patients stabilize, and economies of scale. As the program expands beyond Glenn County, the same platform supports additional clinics and patients without proportionally increasing development or infrastructure cost. The goal of the pilot is a financing structure that stands on its own rather than a program dependent on continued grant funding.
Why this may matter financially — 2026 RPM device codes
For Medicare patients, RPM includes clear device-based billing codes that do not require stopwatch-style time tracking inside the application. The 2026 CMS Physician Fee Schedule introduced a new code (99445) that reimburses at the full device rate for months when a patient transmits just 2–15 days — closing a gap that historically made non-adherent months unbillable.
| CPT | Description | 2026 rate |
|---|---|---|
| 99453 | Setup and patient education | $21.71 (one time) |
| 99445NEW 2026 | Device supply and data transmission, 2–15 days/month | $52.11 /mo |
| 99454 | Device supply and data transmission, 16–30 days/month | $52.11 /mo |
~$5,211
/ month recurring
100 Medicare patients × $52.11 (99445 or 99454). Any patient logging ≥2 transmission days bills the full device rate.
~$62,532
/ year recurring
Annualized device revenue on a 100-patient Medicare panel. Scales linearly with panel size.
~$2,171
one-time setup
99453 across the initial 100-patient cohort. Billed once per patient at enrollment.
Estimated 2026 CMS national non-facility averages. Region and MAC vary — verify against the CMS Physician Fee Schedule lookup.
Time-based management codes (99457, 99458, 99470) are intentionally excluded from this pitch. The whole point of North State Prevention is that the app automates the 20-minute-per-patient clinical monitoring work those codes reimburse. Enloe would only bill them if staff performed additional documented review time beyond the app-driven workflow — those would be additive revenue, not baseline.
Try the prototype
Open either side. All data is synthetic; nothing leaves your browser. Both demos are pre-loaded with patients across every escalation state — controlled, escalating, non-adherent, newly enrolled, and recovered.
Next step
CalRHT timing is short. Enloe will be the regional hub, so the grant narrative can move to finalization. Reach out directly: