Population Health Management: Prevention & Management of Diabetes and Controlling High Blood Pressure in People With Diabetes. December 13th, 2017

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1 Population Health Management: Prevention & Management of Diabetes and Controlling High Blood Pressure in People With Diabetes December 13th, 2017

2 Goal & Objectives Goal: To reduce the proportion of persons with diabetes with an HbA1c value greater than 9 percent Objectives: The health care organizations will: Have an improved understanding of diabetes in MA Have an opportunity to consider your workflow for the most effective teambased care in order to improve outcomes for patients with diabetes 2

3 Millions Current Projections of Cases of Diabetes in the US by 2030 Rates are expected to double by

4 Diabetes Prevalence in Massachusetts 4

5 Financial Cost of Diabetes $245 billion dollars in US diabetes related expenses in Billion in Medical Costs + 69 Billion in reduced productivity People with diabetes have 2.3x the medical costs as those without People with diabetes spend about $13,700 a year on medical costs: $7,900 of which is directly related to their diabetes 5

6 Social Determinants of Health Race (use UDS categories): 1. Asian, Hawaiian/Pacific Islander 2. Black/African American 3. American Indian/Alaska Native 4. White 5. More than one race 6. Unreported/Refused Ethnicity (use UDS categories): (Hispanic/Latino, Not Hispanic/Latino) Poverty Level (use UDS categories): % and below % % 4. Over 200%, unknown Insurance (use UDS primary insurance categories): 1. none/uninsured, 2. Medicaid/CHIP/other Public, 3. Medicare, 4. Private Insurance 6

7 Diabetes Prevalence by Race and Ethnicity Massachusetts Behavioral Risk Factor Surveillance System. 95% Confidence Interval. Adults (18+) only. NH = Non-Hispanic Rates for Asians could not be reported due to insufficient data 7

8 Source: CDC Wonder (Vital Statistics). -95% confidence interval. Age adjustment based on US population in Deaths among all ages. NH=Non-Hispanic. American Indian, NH data is suppressed. ICD 10 codes E10 E14. 8

9 Takeaways for Diabetes Stats in MA Higher Diabetes Prevalence in MA for: Males Low SES population Low educational attainment 65+ age group Urban and rural populations People of color 9

10 10

Screening USPSTF: All adults, aged 40-70 who are overweight or obese ADA: All adults 45

11 Screening USPSTF: All adults, aged who are overweight or obese ADA: All adults 45 and older Adults 18 or older who are overweight or obese AND have at least 1 risk factor 11

12 Testing Retest every year if normal Confirm diagnoses with 2 tests taken on separate days Retest every 6-12 months after a diagnosis 12

13 Massachusetts Clearinghouse 13

14 Developing an AIM Statement The purpose of an AIM statement is to provide QI teams with clear, well defined goal(s) An AIM statement provides the template for an improvement initiative It is a measurable and time-sensitive description of the goal the team expects to make from its improvement efforts It s written in one or two sentences Always includes a numerical goal 14

15 Developing an AIM Statement What system or process are you trying to improve? Indicate the setting of focus and/or population you plan to serve What do you expect to happen? Specify your goal (and amount) of effort that points toward an outcome measure(s) What s your time frame? It should create some urgency and also prevent he work from becoming a never-ending improvement project What other guidelines for the team is useful to know? This might include specific changes to test, methods to use, or limitations 15

16 Example AIM Statements Offer all patients same-day access to their primary care physician within 9 months Reduce waiting time to see a physician to less than 15 minutes within 9 months Improve medication reconciliation at transition points by 75 percent within 1 year Over the next 12 months, we will redesign the care systems of our CHC to decrease the number of poorly-controlled diabetics, so that less than 20 percent of these patients have an HbA1c greater than 9 percent. 16

17 Storyboard Template Collaborative Topic (What aspect of care are you trying to improve?) Describe the gap between current and possible performance (using data is good!) Is there evidence base or best practice describing ideas to close the gap? Describe this. Why is this important to do now? (For patients, your organization, the potential teams) What is the business case for organizations that participate in this Collaborative? Expected start and end date of your collaborative 17

18 Collaborative Driver Diagram Do your best to describe your early theory of what changes the teams will need to test, adapt, and implement in order to reach the Collaborative aim. Use the Driver Diagram Template that follows (template, definitions, and examples included) 18

19 Driver Diagrams Definition A Driver Diagram is an improvement tool used to organize theories and ideas in an improvement effort. It displays visually, our theory about why things are the way they are and/or potential areas we can leverage to change the status quo. The driver diagram is often used to scope or size a project and to clarify the plan for reaching the aim. Primary Drivers: major processes, operating rules, or structures that will contribute to moving towards the aim Secondary Drivers: elements or portions of the primary drivers. The secondary drivers are system components necessary in order to impact primary drivers, and thus reach project aim. Specific changes/change concepts: Specific changes are concrete actionable ideas to test. Change concepts are broad concepts (e.g. move steps in the process closer together) that are not yet specific enough to be actionable but which will be used to generate specific ideas for change. Note: measures can be indicated on the DD as it becomes more mature. 19

20 Driver Diagram Template Primary Drivers Secondary Drivers Specific Ideas to Test or Change Concepts AIM D1 D2 D3 D4 D5 20

21 Driver Diagram Example AIM Primary Drivers Correct indications Secondary Drivers Document decisions Identify failures Specific Ideas to Test or Change Concepts Standardize order forms Daily huddles Reduce CAUTI by 30% compared to the 2010 baseline by August 31, 2013 Daily reviews Hardwired process Teamwork Communication Script rounds/daily huddles Involve pts/caregivers Effective infection control Hand hygiene Sterile technique Collection bag positioning Visible reminders for aseptic technique Assemble insertion kits Educate ancillary staff Sample collection Prompt removal Forcing functions Reduce reactheterization Make post-op removal the default option Develop contingency plans for retention Engaged leaders Failures front of mind Attention to improvements Report CAUTIs monthly Present patient stories Leadership reality rounding Make results visible on units 21

22 Your Teams and Faculty Who are the potential teams you would invite to join (for example, from mental health clinics, primary care clinics, etc.)? Who might your faculty be? 22

23 Spread Planning Do you expect to spread the work of your Collaborative teams to the rest of your organization? What is the timetable for this? What (or who) are the appropriate "units" for adopting changes from your change package? (Who will make the decision to begin using the new ideas in their practice? Some examples of potential units include physicians, surgeons, emergency departments, hospitals, nursing units in a hospital, clinics, laboratories, or pharmacists.) How many total units do you intend to spread to? (This could be all eligible units or some defined subset of them.) How many units will you select to attend your initial Collaborative? What percentage of the total units is this? How will you select these initial units? 23

24 Next Steps Theorize proposed solutions PDSA test of change Design storyboard 24

25 Thank you Perrin Braun Mass League Coach

26 An overview of the AHA/AMA initiative to help physicians and patients control high blood pressure. 26

Introduction 1 in 3 Americans is living with the silent killer, putting them at an increased risk for heart attack, heart failure, stroke and other health problems 1 It s time to get serious The

27 Introduction 1 in 3 Americans is living with the silent killer, putting them at an increased risk for heart attack, heart failure, stroke and other health problems 1 It s time to get serious The number of people with high blood pressure is growing at an alarming rate. Currently 1 in 3 Americans, about 85 million people, is living with the silent killer, putting them at an increased risk for heart attack, heart failure, stroke and other health problems. Fortunately, high blood pressure can be treated and managed. Maintaining lower blood pressure can reduce the risks of significant health events and lead to better outcomes. It starts with the comprehensive national initiative Target: BP. We re counting on you to help raise awareness of high blood pressure s impact and to work with your patients to help them get it controlled. The materials outlined in the Tools and Resources portion of this deck are available to support your hypertension management efforts. 1. Benjamin EJ, Blaha MJ, Chiuve SE, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics 2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146-e603. Section 27

Insights An opportunity for change Most physicians are confident in their ability to treat high blood pressure. They understand the condition, its causes and the approaches to treating it.

28 Insights An opportunity for change Most physicians are confident in their ability to treat high blood pressure. They understand the condition, its causes and the approaches to treating it. However, the number of Americans living with high blood pressure continues to rise as the time physicians are able to spend with each patient declines. What s more, you know that people living with high blood pressure often don t have the necessary level of urgency surrounding their condition. Patients may start a treatment plan, but short-term improvements can lead to an assumption that returning to their previous lifestyle is acceptable (there can also be cultural influences that are difficult to change). It can be frustrating that patients often don t do everything they should be doing to get, and stay, healthy. Everyone is looking for the tools, resources and support that can help them create successful partnerships and yield better outcomes. Section 28

Initiative Overview An opportunity seized. Committed to a common mission, the AHA and AMA developed and piloted Target: BP in 2015 to improve blood pressure control.

29 Initiative Overview An opportunity seized. Committed to a common mission, the AHA and AMA developed and piloted Target: BP in 2015 to improve blood pressure control. Devoted to building a healthier nation, this national initiative aims to reduce the number of Americans who have heart attacks and strokes by urging medical practices, health service organizations and patients to prioritize blood pressure control. Given the current urgency, Target: BP raises awareness and provides additional tools and resources for physicians and their care teams to help the patients they treat. Target: BP can also help optimize the limited time physicians have with patients to help get patients healthier sooner. In addition, our recognition program offers additional practice-building and recognition incentives. Section 29

30 Table of Contents Overview Tools and Resources Recognition Program Improving control Making a connection Promoting success Section 30

31 OVERVIEW Improving control A plan for managing high blood pressure Section 31

32 Initiative Process Working toward a healthier America Step 1: Customize a Plan After registration, a Target: BP staff member will work with you to create a customized implementation plan for your practice. At the center of every plan is the Target: BP Improvement Program. The BP Improvement Program leverages the M.A.P. framework, which focuses on three key aspects of successful care for patients with hypertension. 2 Target: BP supports you by offering access to: Tools, resources and improvement plans, including a customizable algorithm with proven efficacy Best practices and success stories from other Target: BP participants Easy-to-use tools and resources to help your patients better understand the importance of controlling blood pressure Step 2: Measure Improvement and Report Results Staff will offer support to you by helping to identify quality improvements, providing guidance on data reporting and giving feedback on measurement results. Step 3: Promote Recognition Target: BP recognizes and rewards participating practices for improving the outcomes of their patients with hypertension. All practices who join Target: BP and submit patient data will be recognized, and those that achieve a 70-percent or greater blood pressure control rate within their adult patient population will receive additional incentives to acknowledge their above-and-beyond efforts. 2. Boonyasai RT, Rakotz MK, Lubomski LH, et al. Measure accurately, Act rapidly, and Partner with patients: an intuitive and practical three-part framework to guide efforts to improve hypertension control. J Clin Hypertens (Greenwich). 2017;19(7): Copyright 2015 American Medical Association and The Johns Hopkins University. All Rights Reserved. This tool was adapted with permission of the American Medical Association and the Johns Hopkins University. All Rights Reserved. This tool can be found at Copyright 2017 American Medical Association and The Care Coordination Institute, LLC. Section 32

Target: BP Improvement Program Click a circle below to view detailed information Target: BP Improvement Program Measure Act Partner The Target: BP Improvement Program leverages the latest clinical

M is for MEASURE blood pressure accurately every time Proper measurement is critical to controlling blood pressure. Build a protocol to ensure accuracy of blood pressure readings.

33 Target: BP Improvement Program Click a circle below to view detailed information Target: BP Improvement Program Measure Act Partner The Target: BP Improvement Program leverages the latest clinical evidence to make it easier for you to more effectively manage your patients with high blood pressure. The BP Improvement Program has three main parts, which can be remembered using the acronym M.A.P.: Measure accurately; Act rapidly; and Partner with patients, families and communities. M is for MEASURE blood pressure accurately every time Proper measurement is critical to controlling blood pressure. Build a protocol to ensure accuracy of blood pressure readings. A is for ACT rapidly to address high blood pressure readings This step requires rapid action during a patient visit and prioritizes follow-up appointments and a clear treatment plan to help patients achieve blood pressure control. P is for PARTNER with patients, families and communities to promote self-management Real change comes when patients take ownership of their health. Engage with patients, their families and communities helps to promote sustainable lifestyle change, thus supporting the improvement of overall health. The BP Improvement Program uses a team-based care approach where data drives improvement. Your practice will utilize hypertension qualityimprovement metrics to monitor the impact of your efforts. Furthermore, you are encouraged to reach out to uncontrolled patients who need to return to the office for follow-up. Typically, within a six-month period, a practice that implements the BP Improvement Program can expect to see lower blood pressure and improved control rates in patients with hypertension. Section 33

34 TOOLS AND RESOURCES Making a connection Additional resources to help reach Target: BP goals Section 34

Target: BP Resources Resources for every step of the process In order to ensure a successful experience with Target: BP, valuable resources are being made available to you

Used together, your practice will be more prepared to treat the condition, and patients will be aware of what they need to do to get and stay healthy.

35 Target: BP Resources Resources for every step of the process In order to ensure a successful experience with Target: BP, valuable resources are being made available to you and your practice, as well as to the general public and to patients who have made the choice to re-engage with their high blood pressure management plan. Used together, your practice will be more prepared to treat the condition, and patients will be aware of what they need to do to get and stay healthy. For Practices Recognition Plaque Target: BP Starter Kit Conversation Guide for Discussions With Patients Target: BP HCP Website For Patients Targetbp.org LowerYourHBP.org Website for Public Awareness and Patients Section 35

Physician Resources Recognition Plaque Practice-building visibility To further display your commitment to lowering high blood pressure, a

Each year, following analysis of uploaded patient data, you can receive a commemorative medallion aligning to your level of achievement,

Over the years your practice can accumulate achievement medallions to show your longstanding commitment to helping patients achieve blood

36 Physician Resources Recognition Plaque Practice-building visibility To further display your commitment to lowering high blood pressure, a Target: BP program plaque will be given to your practice when your practice has joined and uploaded your first year data. Each year, following analysis of uploaded patient data, you can receive a commemorative medallion aligning to your level of achievement, which can be inserted into your plaque. Over the years your practice can accumulate achievement medallions to show your longstanding commitment to helping patients achieve blood pressure control. You can build additional visibility through promotion using social media messages, digital seals and banners, and a press release that will be ed to Target: BP participants. You can view the entire list of recognition items here. Section 36

Physician Resources Starter Kit A quick start for faster adoption The Starter

Created to provide you with essential information and tools, this

and AMA introducing the Target: BP initiative Right Way Every Time Wall Chart

blood pressure readings Overview Brochure High-level take on the Target: BP

Improvement Program Brochure Simple and informative piece detailing key

37 Physician Resources Starter Kit A quick start for faster adoption The Starter Kit is a self-contained practice resource. Created to provide you with essential information and tools, this comprehensive resource can help improve patient conversations and lead to better outcomes. The Starter Kit includes: Introduction Letter Joint communication from the AHA and AMA introducing the Target: BP initiative Right Way Every Time Wall Chart An in-practice wall chart outlining the 7 key points to consider for accurate blood pressure readings Overview Brochure High-level take on the Target: BP initiative highlighting mission and initiative components Target: BP Improvement Program Brochure Simple and informative piece detailing key aspects to improve blood pressure control Self-Measured Blood Pressure (SMBP) Brochure Recommendations with specific, step-by-step techniques for patients to effectively monitor their own blood pressure Section 37

Physician Resources Starter Kit Practice-building

-branded items that show your practice s commitment to

participation in the initiative to your patients.

38 Physician Resources Starter Kit Practice-building visibility Also included in the Starter Kit are Target: BP -branded items that show your practice s commitment to lowering high blood pressure and creating a healthier America. These recognition pieces can be used to highlight participation in the initiative to your patients. Wall Cling 1 per kit Table Tent Desk Stand 1 per kit Post-It Pads 2 per kit Pens 2 per kit Stethoscope Clips 5 per kit Lanyard 3 per kit Section 38

Physician Resources Conversation Guide Productive in-office conversations When a patient takes that first step to re-engage, it s crucial that your exchange with him or her is meaningful.

39 Physician Resources Conversation Guide Productive in-office conversations When a patient takes that first step to re-engage, it s crucial that your exchange with him or her is meaningful. To help facilitate that objective, use this comprehensive conversation guide to enhance patient conversations around hypertension. Covering such topics as the dangers of high blood pressure, treatment approaches and home monitoring instruction (also known as SMBP) among others, this guide supports and encourages a positive back-and-forth. Designed to ensure patient retention of key points, this bilingual guide is tabbed for easy access to each section and written at a level that is appropriate for patients. Section 39

40 Physician Resources Website Easy access to innovative resources Visit targetbp.org as a first step in learning more about the Target: BP initiative. All of the tools and resources contained on the site are optimized to ensure that you have quick access to exactly what you need. Section 40

Patient Resources User-friendly learning and discovery Patients seeking additional information about high blood pressure can learn about having an open conversation with their physician at

41 Patient Resources User-friendly learning and discovery Patients seeking additional information about high blood pressure can learn about having an open conversation with their physician at LowerYourHBP.org. The website also has a number of valuable tools and resources that can be reviewed and downloaded as patients prepare to re-engage with high blood pressure management. Section 41

42 RECOGNITION PROGRAM Promoting success Rewarding your contributions and encouraging participation Section 42

Recognition Program The right rewards at the right time The Target: BP Recognition Program was designed to allow practice sites and health systems to get the recognition they deserve for making a

43 Recognition Program The right rewards at the right time The Target: BP Recognition Program was designed to allow practice sites and health systems to get the recognition they deserve for making a commitment to prioritize blood pressure management within the patient populations they serve. This program rewards Target: BP registrants who have set goals and are working to implement clinical protocols to help at-risk patients meet and sustain blood pressure control rates of 70 percent or greater. Section 43

Recognition Levels All efforts recognized The Target: BP Recognition Program is as dynamic as the physicians and care teams

With that in mind, a comprehensive list of items, ranging from self-promotion to national-level acknowledgments, was created to

In 2017, there are two levels of recognition: Participant and Gold, which are based on the level of blood pressure control

44 Recognition Levels All efforts recognized The Target: BP Recognition Program is as dynamic as the physicians and care teams being recognized. With that in mind, a comprehensive list of items, ranging from self-promotion to national-level acknowledgments, was created to showcase your practice s commitment. In 2017, there are two levels of recognition: Participant and Gold, which are based on the level of blood pressure control achieved within your practice s patient population. Participant-Level Achievement Practices that join the Target: BP initiative and submit patient data qualify for recognition Gold-Level Achievement Practices reaching 70-percent blood pressure control or greater in their patient population will receive premier recognition Section 44

Participant- and Gold-Level Recognition Something for everyone This comprehensive offering of recognition items was carefully selected for physicians and their care teams.

45 Participant- and Gold-Level Recognition Something for everyone This comprehensive offering of recognition items was carefully selected for physicians and their care teams. By participating in the Target: BP initiative and submitting patient data, practices at the Participantlevel receive multiple recognition items throughout the year. Practices reaching 70-percent blood pressure control or greater in their patient population are at the Gold level and receive premier recognition. Section 45

46 Recognition Data Overview Data submission The data submission process occurs annually, beginning in the first quarter of each year. You will be notified of the opening of the submission window via the Target: BP Newsletter. Your practice will need to submit data for the prior calendar year to calculate the blood pressure control rate measure based on NQF #0018/PQRS #236/ACO #28.* Participating sites will receive a message if the data they submit has errors. Data will be saved as a draft with errors to allow the practice to review and resolve the issue(s). *NQF #0018 is endorsed by the National Quality Forum (NQF). In CMS programs, it's designated as "PQRS #236." It's also used for quality benchmarking and reported as ACO #28 for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program. Section 46

Recognition Data Overview Qualifying data to provide Number of adult patients with a diagnosis of hypertension (measure denominator) Number of adult patients with a diagnosis of hypertension whose

47 Recognition Data Overview Qualifying data to provide Number of adult patients with a diagnosis of hypertension (measure denominator) Number of adult patients with a diagnosis of hypertension whose blood pressure was controlled at <140/90 mm Hg (measure numerator) Data inclusion/exclusion: Target: BP collects data for adult patients ages 18 to 85 for the reporting year data. Patients with end-stage renal disease, dialysis, renal transplant or pregnancy are excluded from this patient population Additional patient population elements: Age, gender, race and ethnicity data (for the Million Hearts Hypertension Prevalence Estimator Tool) Section 47

48 Recognition Data Overview Data support within reach Target: BP staff will be available to walk you through the data submission process. They will be able to support your efforts to improve patient outcomes with an in-depth knowledge of your practice, your reporting capabilities and the needs of your patient population. For more information on data submission and related resources, please visit targetbp.org/recognition-program/. Section 48

Further questions on Target: BP can be directed to one of your local AHA staff below: Cherelle Rozie, Multicultural Initiatives Director, cherelle.rozie@heart.

49 Further questions on Target: BP can be directed to one of your local AHA staff below: Cherelle Rozie, Multicultural Initiatives Director, Stefanie Smith, Community Health Director, 2017, American Heart Association, Inc. 10/17 Copyright 2017 American Medical Association. All rights reserved. 49

WEBINAR: Check. Change. Control. Cholesterol April 4, 2018

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