Improving Hypertension Through Public Health and Primary Care Collaboration Sarah Nelson MD/Marsha Green RN COO/Dan Schletty BS Rural Health Conference 2015 June 29, 2015
Objectives Describe the public health and primary care partnership as a means to accelerate clinical attention on addressing hypertension using the NQF 18 results and other resources Understand the benefits of practice facilitation in making clinical quality improvement changes Understand the role of a clinical health coach and other team members in hypertension control Comprehend the importance of home blood pressure monitoring as a patient self-management tool.
ASTHO Million Hearts Learning Collaborative ASTHO - Association of State and Territorial Health Officers 9 States and District of Columbia 9 month project Oct 2013 - June 2014 Million Hearts Initiative - National Initiative to prevent 1 million heart attacks and strokes by 2017
ASTHO Million Hearts Project overview Goal : Improve the use of Health Information Technology and team based care to get greater blood pressure control in selected states/locales Focus on NQF 18: The percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose BP was adequately controlled during the measurement year.
ASTHO Million Hearts Project Partners Minnesota Partners o MDH o CCLStL CHB o Stratis Health o 4 NE MN primary care clinics
ASTHO Million Hearts Project Aim Minnesota Aim Pilot the use of NQF 18 (hypertension control measure) to identify and manage hypertensive patients using a team based approach, showing an absolute improvement of 5% aggregated across the clinics
ASTHO Million Hearts Project Features Practice Facilitation Learning Collaborative Data collection o NQF 18 HTN Control Protocols
Practice Facilitation Grant Team Clinics teams o o o o o o o Coordinator Provider Champion Nursing/Rooming Assistant Data Analyst/Health Information Technology Quality Improvement Referral Coordinator Community Health Workers/Health Coaches/Care Coordinators
Practice Facilitation Components Regular Meetings Data gathering and review Using PDSA cycles for clinic flow, policy and protocol changes o o o o Plan Do Study Act
Learning Collaborative Webinars 5 Webinars 1. Organizational Tips to Improve Hypertension Control - Dr. Kottke Health Partners 1. Clinical Designs to Promote Healthy Lifestyles and Risk Reduction - Renee Gust MA RN Hennepin County Public Health 1. EHRs to Achieve Success with Hypertension - Dr. Kleeberg Stratis Health 1. Combining Medicine and Technology to Improve Quality and Transform Healthcare to Improve Blood Pressure Control - Dr. Tashjian Ellsworth Medical Clinic 1. ASTHO Million Hearts in Minnesota - First Look at Your Data - James Peacock PhD MPH Minnesota Department of Health
Learning Collaborative Face to Face face to face learning day - Healthy Lifestyle/Risk Reduction pilot measure - Monthly data review - Medication Therapy Management - Clinic PDSA cycle reports - Moving Forward in the World of ACO s - one clinics best practices
Learning Collaborative Health Coaching Seminar Clinical Health Coaching Seminar - Clinical Health Coaching - Motivational Interviewing - Community Health Worker - Coding, Billing and Payment Issues
Learning Collaborative Feedback Collaboration through webinars and face to face meetings helped us to learn from others experiences Useful insights from others experiences Collaboration with other clinics is always very helpful
Data Collection NQF 18 NQF-0018: Controlling High Blood Pressure o The percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose BP was adequately controlled during the measurement year. o Baseline June 1, 2012 - May 31, 2013 o Final June 1, 2013 - May 31, 2014
Aggregate NQF18 Page 1
Aggregate NQF18 Page 2
Aggregate NQF18 Page 3
NQF18 Base Line and Final Data
Protocols Accurate Measurement of blood pressure Hypertension Treatment Home Blood Pressure Monitoring
Protocols Accurate Measurement of Blood Pressure Improving the Screening, Prevention and Management of Hypertension - Washington State Department of Health
Protocols Measurement of Blood Pressure Improving the Screening, Prevention and Management of Hypertension - Washington State Department of Health
Causes of Inaccurate Measurement of Blood Pressure
Protocols Accurate Measurement of Blood Pressure Resources Wisconsin Department of health Services: Blood Pressure Measurement Toolkit Institute for clinical systems improvement Health Care Guideline: Hypertension Diagnosis and Treatment
Protocols Accurate Measurement of Blood Pressure Trainings All four clinics had some form of competency training for measurement of blood pressure All four clinics found room for improvement and consistency with measuring blood pressure
Protocols Hypertension Treatment
Evidence Based Protocols Hypertension Treatment There are at least 6 major benefits of adoption and use of standardized, evidence-based protocols:" 1. Protocols reduce clinical variability that is outside the bounds of evidence-based practice." 2. A protocol can better enlist and enable all members of the health care team to reinforce the importance of blood pressure control and the value of adherence to healthy habits, medications, and self-monitoring, and to participate in medication titration and adjustment by following standard protocol-consistent order sets. Such clarity allows qualified staff to advance patients safely and efficiently along the treatment pathway, ensures that the supervising clinician is consulted if clinical exceptions occur, and identifies patients likely to benefit from consultation for resistant hypertension." 3. Algorithms can be incorporated into electronic health records through clinical decision support tools, registry functions, and measurement to facilitate quality improvement."
Evidence Based Protocols Hypertension Treatment Continued There are at least 6 major benefits of adoption and use of standardized, evidence-based protocols:" 4. A protocol can result in a more efficient and cost-effective selection of medications and treatment approaches." 5. Standardized treatment facilitates evaluation, both of the quality of care and of the impact of care." 6. Adopting a standardized treatment approach sends a strong signal to clinical staff that hypertension control is a priority."
Sample 1 Protocols Hypertension Treatment
Sample 2 Protocols Hypertension Treatment
Protocols Home Blood Pressure Monitoring Million Hearts website: http://millionhearts.hhs.gov Self-Measured Blood Pressure Monitoring link: http://millionhearts.hhs.gov/docs/mh_smbp.pdf
Team Based Care Marsha Green BA RN Essentia Health Deer River
Team Based Care Essentia Health Create and support a coordinated TEAM approach to delivering health care The increasing complexity of primary care medicine makes it no longer possible for one individual or discipline to comprehensively manage all aspects of patient care.
Care Team Practice Model Deer River
Teams Are the fundamental unit of care delivery Inter-professionally competent Defined roles and care processes Planned huddles & smooth communication flow Quality improvement planning Access management Tele-care support with Gaps in Care
Team Meeting Agenda: Medical Home Patient-specific actionable Review specific cases (1 to 2 cases per meeting) Requires team discussion or problem-solving Case finding Risk stratification report review Quality improvement opportunities Performance review quality planning Review team quality performance (at least monthly) CDM scores; screening rates Gaps in care; out of contact patients Other dashboard items Key for success Include patients on your team pay stipend, seek input, follow-up Regular meetings, set agenda Serve food
Team members for HTN Care Health Coaching Health Coaching Clinical Health Coach Fusion program which entails both online and in person training, see link here: http://clinicalhealthcoach.com/ Tobacco Treatment Specialist Training from Mayo Clinic in Rochester-5 day course, see link here: http://www.mayo.edu/research/centers-programs/nicotine-dependence-center/educationprogram/tobacco-treatment-specialist-certification/tobacco-treatment-specialist-certification Living well with Chronic Disease-Provider and self-referral based Certified Lactation Counselor 5 day course, see link here: http://www.healthychildren.cc/
Team members for Home Blood Pressure Monitoring Home Blood Pressure Monitoring All staff are involved with the Home Blood Pressure Monitoring Program Provider Referral - Consistent guidelines for program enrollment Enrollment - Clinical Assistant (CA)/LPN/MA Follow-up - CA and Provider Current turn around time is four-six weeks, with physicians making medication adjustments and being able to track their patients blood pressure after those adjustments. Better tracking means better diagnosis and treatment
Home Blood Pressure Monitoring Continued Home Blood Pressure Monitoring Started with three home blood pressure machines at the beginning of the trial/grant period Added twenty more machines in April 2014 due to success with the program and another five in March 2015 Expanded the program at that time to include the clinics in Remer and Grand Rapids Incorporated teaching to include healthy lifestyle changes Created a document titled What can I do to control my high blood pressure? Available Essentia wide Supplements education for newly diagnosed and chronic hypertension patients
Background Introduction Information Dan Schletty Exercise Science (B.S.) MHA in Healthcare Operations (2017) Certified Personal Trainer, Health Coach (ACE) Certified Tobacco Treatment Specialist (Mayo Clinic) Certified Clinical Health Coach 39
25-bed Critical Access Hospital 3 Primary care clinics Specialty clinic Surgical services 375 employees Collaborative partnerships Riverwood Healthcare Center Integrated System
Health Coaching in Primary Care Launched integrated coaching program in Spring 2013 Free of charge To date: >600 PCP referrals
Health Coaching in Primary Care Structure was key for provider buy-in: Embedded into EHR Coaching templates SMART goal setting Coaching care paths, workflows, stratification table, predictive modeling
Patient-Centric Integrated Care Preventive Health Screens Path to Engagement & Health Outcomes Health Risk Assessment Lifestyle & Behavior Modification Motivational Interviewing Accessibility to coach Internal Referral External Self- Referral Targeted Lifestyle Changes (SMART Goals) Improve Condition Awareness Health & Wellness Coaching (Patient Engagement) Importance and Confidence of Goal Setting Community Resources Communication with PCP & care team Patient Satisfaction Testimonials New Patients Improved Quality of Care Health Outcomes MNCM Improved Quality of Life Referrals Internal Referrals External Referrals Empathy & Support Trust EMPOWER SELF CARE
Home BP Monitoring 44
Home BP Monitoring Checkout Log: BP Log for patient: Added Home BP Average to vitals: 15 total BP units Located in all 3 clinics Positive feedback from PCP s
Only 192 patients in the NQF-18 denominator worked with a Health Coach over 6 months Little change in patients seeing Health Coach only once or twice (+0.6 pct points) Huge improvements in HBP control in patients seeing Health Coach at least 3 times (+26.8 pct points) Impact of Health Coaching on HBP Control Health Coach Visits NQF-18 Baseline NQF-18 Final % Change NQF-18 Patients Denominator Numerator None 59.1% 62.5% + 3.4 3,341 2.087 1-2 55.8% 56.4% + 0.6 110 62 3 or more 50.0% 76.8% + 26.8 82 63
Coaching Outcomes
6/6/14: 253 lbs. 5/7/15: 188 lbs. (-63 lbs.) Success Story: #1 56 y/o female, obesity, HTN 6/6/14: 143/87 (Started HCTZ 25 mg) 5/7/15: 123/60
Success Story: #2 56 y/o female, depression, HTN, Obese Home BP monitoring increased awareness & acceptance of HTN