Hypertension Best Practices Symposium Sponsored by AMGA and Daiichi Sankyo, Inc.

Transcription

1 Hypertension Best Practices Symposium Sponsored by AMGA and Daiichi Sankyo, Inc. October 13-15, 15, 2010 Scottsdale, AZ Kaiser Permanente of the Mid-Atlantic States (KPMAS) 1

2 KPMAS Medical Group Profile Kaiser Permanente established in California in 1945 Expanded to Washington metro area in Primary Care Physicians 635 Specialty Care Physicians in ~ 40 specialties and sub-specialties ~ 500,000 members More than 5 million encounters/year 2 Epic Systems used for EMR

3 Service Area 36 Office Buildings 3 Jurisdictions MD, VA, and DC 5 Core contracted hospitals

4 HEDIS Performance Percentage Measurement Year BP < 140/90

5 Foundational Principles Benchmark within a system Transparency Design a system to perform 100% of the time Treat to target: close is not good enough Monitoring Titration Medication adjustment Maintenance program

6 Goals & Objectives Objective: Create systematic and reliable workflows and systems that allow staff to work to their maximum scope of practice while eliminating barriers and missed opportunities Goals (subject to change in 2011 based on ACCORD) Achieve control to HEDIS 90 th percentile: 73% Achieve control to HEDIS 90 th percentile for Diabetes: 75.7% (< 140/90) 6

7 Population with Hypertension 116,150 Uncontrolled Hypertension 51,507 Diabetes 41,785 Hypertension and Diabetes 34,942 Uncontrolled Hypertension and Diabetes 20,708

8 Team Composition Medical Group and Health Plan Leadership Primary Care and Specialty Care Physicians Nurses and Nurse Managers Nurse Practitioners Clinical Assistants Case/Care Managers Advice Nurse and Appointment Representatives Pharmacists Analysts EMR Development Team Information Technology Developers Population Care Management project managers 8

9 Chronic Care Model Home Environment Community Influences (Work, School, Media, Friends) Environmental Factors Self- Management support Patient Behavior Health Outcomes Delivery System Design Prepared, Proactive HCT Information Systems Health Care System Factors Decision Support Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4

10 Chronic Care Model (system) Self- Management support Patient Behavior Prepared, Proactive HCT Trained staff with open schedules Feedback reporting Practice Gdlns Delivery System Design Decision Support EMR alert for BP results with triage Alert for nephrotoxic meds Alert for pts with DM over 55 without ACE-I Health Outcomes Information Systems Health Care System Factors Web based panel management tool

11 Chronic Care Model (patient) Health coaching (re: diet, exercise) Patient Information on post visit summary Home Environment Community Influences (Work, School, Media, Friends) Self- Management support Access to medical record online NP Care Manager Newsletter Patient Behavior Environmental Factors Health Outcomes

12 Clinical Practice Guidelines

13 EMR Decision Support Alerts and smartsets created in specialty care departments to assist Clinical Assistants with follow up care based on BP BP goal <125/75 and above goal BP goal < 135/85 and above goal BP over 170/105 regardless of goal

14 Clinical Education CMEs Pocketcards Academic Detailing MegaMeeting quality-focused video/audio presentations Posters Inreach training and support Competency training

15 Supporting Self-management kp.org/healthyliving Health Encyclopedia Healthy lifestyle programs on: Total health assessment -HealthMedia Succeed Weight management program - HealthMedia Balance Create a nutrition program - HealthMedia Nourish Stress Management program - HealthMedia Relax Smoking Cessation program - HealthMedia Breathe Revised Healthy living class Discount to Weight Watchers program Offer 10,000 Steps Program Pedometer and Step tracking program Discount at fitness facilities

16 Supporting Self-Management Tracking cards for self-management Outreach letters After visit summary listing BP results, medications, and patient instructions My Health Manager (kp.org) Posters in offices Newsletter

17 Outreach Letters

18 After Visit Summary

19 My Health Manager

20 Poster Displayed in exam rooms and triage rooms throughout the Medical Office Buildings.

21 2009 Patient Newsletter

22 Inreach Process

23 Performance Feedback

24 Performance Monitoring

25 HEDIS 2010: NOT AT GOAL Controlling HTN: 65.21% Goal is HEDIS 90 th percentile: 73% requires 1570 more people in control Diabetes: BP Control <140/90: 66.42% Goal is HEDIS 90 th percentile: 75.7% requires 1214 more people in control

26 Intervention Approaches Clinical Assistant blood pressure check and triage Blood Pressure Program - BPP (PharmD and RN) Supports physician practice Supplements physician appointments Enhances CA/member relationship Increased patient compliance - Rx instructions repeated often 26

27 BPP Pilot Overview Number of Patients: 20,534 Patients with HTN: 8,169 Patients with Diabetes: 2,977 Exclusion criteria: Followed by specialty care, i.e. Cardiology, Nephrology Pregnant < 18 years old 27

28 BPP Pilot Workflow Encounter with Pharmacist and/or RN Review previous BP readings Review medications, including overthe-counter Assess adherence Offer behavior change counseling

29 BPP Pilot Program Results Demographics Male Female Average age African American Caucasian Asian Target BP 140/90 130/80 Results N = 39* pts with BP > 140/ Represents about 75% if pts enrolled in clinic from 10/09 to 2/10.

30 BPP Pilot Program Results No. of Visits No. of Pts Average BP Reduction in mean BP from baseline No. of Pts at Target BP /85 N/A /80-7 mm Hg SBP 12-5 mm Hg DBP /79-10 mm Hg SBP 5-7 mm Hg DBP /70-24 mm Hg SBP 6-21 mm Hg DBP /76-30 mm Hg SBP 3-20 mm Hg DBP More 1 132/84-40 mm Hg SBP 1-12 mm Hg DBP

31 Early Improvement in Summer 2010 Crossing the Quality Chasm: KPMAS Internal Tool P ercen tag e o f P atien ts at Target Target: 79% Target: 57% May- 09 Jun- 09 Jul- 09 Aug- 09 Sep- 09 Oct- 09 Nov- 09 Dec- 09 Jan- 10 Feb- 10 Mar- 10 Apr- 10 May- 10 Jun- 10 Jul- 10 Aug- 10 Month HTN & BP < 139/89 Diabetes & BP < 129/79

32 Successes Service Line based management structure (vs. facility-based management prior to 2010) allows for consistency in managing staff expectations and workflows Increasing capacity for BP checks Multi-disciplinary participation Working to the maximum scope of practice and ensuring competency on BP readings Focus on self-management skills No additional co-pay Medication reconciliation and consolidation

33 Challenges or Obstacles RN and PharmD availability No workflow for patients lost to follow up Low physician referral rates Lack of dedicated resources Collaborative practice regulations Scope of practice Competing priorities 33 Economy

34 Future Steps Maximize patient use of self-management education and skill-building Fully implement Clinical Assistant BP checks and PharmD/RN support Fully implement and integrate EMR alerts into daily workflows Maximize staffing efficiency Tailor interventions based on race/ethnicity/learning preference 34

35 Lessons Learned Pushing through resistance is difficult, but necessary. Involving physicians and staff at all levels and in all departments is key. Increase in awareness and buy-in Improves interventions at the time of the visit Greater patient volume screened Members respond when multiple staff and departments address care gaps Increasing BP screening in specialty departments increased number of members referred back to primary care. Involving physician extenders (NP/Pharmacist) for hard-to-reach members who hadn t benefited from care with traditional MD intervention shows results. Engage readiness to change assessment and motivational interviewing techniques Support physician s approach to panel management Group appointment dynamics promoted and improved member behavior change 35

36 Questions How do you reverse clinical inertia? What combination of outreach phone calls, letters, s works best? Any innovative approaches? How do you use incentives for physicians? Staff? Do you have experience with tailoring interventions based on race and/or ethnicity and/or socioeconomic status? What s your staffing ratio? How have you increased class/group participation? 36