Overview of Heart Health Now! 1 Overview of Heart Health Now! Hearth Health Now is the North Carolina Cooperative for AHRQ s project, Evidence Now.
2 Welcome by Samuel Cykert, MD Professor of Medicine and Director of the Program on Health and Clinical Informatics Hi, I m grateful for the opportunity to talk to you about Heart Health Now. This is the North Carolina effort to enhance cardiovascular risk reduction through supporting primary care practices across the state. This effort is funded by the Agency for Healthcare Research and Quality and part of the national effort that AHRQ has dubbed Evidence Now. There only six of these awards across the country chosen to do this work. However, the intent is to prove the value of supporting primary care, especially in rural and underserved areas and finding ways to spread the model widely. The major partners in North Carolina are UNC Sheps Center for Health Services Research, the North Carolina Area Health Education Center nurse program, and Community Care of North Carolina. To put the meaning of this project in perspective, I ve been practicing internal medicine in North Carolina for 30 years starting with my solo practice in days in Alamance County. It s difficult for me to count the number of middle-aged folks that I ve seen in the emergency room and hospital who suffered paralyzing strokes, or debilitating heart attacks well before their time. I ll be talking about how primary care can alter this trajectory by using some of the help available through Heart Health Now. Thanks for listening.
3 Heart Health NOW Why are we doing this? Well, in North Carolina population data, cardiovascular death is by far the number one cause of death in the state. And in terms of national rankings, we re the 32 nd worst in cardiovascular risks and death. The annual cost to North Carolina is almost $5 billion a year for in-patient care alone. So, you can imagine that adding loss of work and outpatient expenses, and medications that the cost is really out the roof. In terms of risk factors, we have a long way to go. So, as you look at this list that I have in front of you, 32% of the adult population is hypertensive; 10% diabetic, 20% smokers, 40% have high cholesterol, and all these problems are amenable to direct intervention in primary care practice, and even with the high prevalence of obesity and overweight, and the lack of physical activity, practices can either give some pretty good simple advice, and/or refer patients to community organizations that can work on these issues further.
4 Heart Health NOW So, the thing that s most important to understand is, we can make an impact, and the impact is pretty fast. So, in these measures you don t have to fix all five or six of them. If you only affect one or two measures and make the positive change with your patients, then in some instances you can reduce the chance of a heart attack, a stroke, or death by as much as 25% within two years. And if all the measures are controlled, it actually reduces the lifetime risk of cardiovascular mortality by 75%.
5 Heart Health NOW Why now? Why are we doing this now? Well, first of all, we want to get heart health better in North Carolina. But the other thing to understand, and I say this as a primary care physician, this is our time. Policymakers are finally recognizing the promise of primary care to both prevent chronic disease, and once patients have chronic disease, if it s systematically managed, we can prevent and delay the advancement to late complications.
6 Advancing Heart Health in NC Primary Care So, the major goals of this study as funded by AHRQ are: 1. To reduce cardiovascular risks both in terms of morbidity and mortality. 2. To advance the promise of primary care and quantitatively prove its value, and 3. To set up an effective system of dissemination and implementation that will help small practices thrive in a value-based care environment.
7 Heart Health NOW We also have to ask ourselves, are we ready? Because to succeed in this, primary care practices must build systems of care that quickly stratify patients for risks, and also, then, build systems of rapidly engaging and re-engaging these high-risk patients to both enhance treatment and to promote lifestyle changes.
8 Heart Health NOW So, what are the measures that we re working on? These are directly related to the ABCS measures that you d associate with the Million Hearts campaign. We are going to use Cardiovascular Risk Assessment, particularly the pooled risk calculator that predicts 10-year risks for each patient, because we want you to be able to take care of your high-risk patients first and rapidly modify their risks. But we ll be looking at, first of all, aspirin both for folks who already have some element of vascular disease, and also using aspirin for primary prevention. But the new way that we ll be doing it is, we ll risk assess the folks who don t actually have cardiovascular disease, and we ll be able to give advice as to who s at high risk and needs aspirin right now, and those who are at low risk where aspirin would be a bigger problem than a benefit. We ll also be looking at the B s and C s which are blood pressure control and cholesterol management and CMS, and the National Quality Foundation will be putting out new measures in these areas within the next six months to a year or so. The blood pressure measure will be based on JNC 8 requirements and recommendations, and the cholesterol management measure will be an adaptation of the American Heart Association 2013 recommendations. And, again, we ll be pushing good, old smoking cessation counseling, and we ll have a lot of emphasis on the use of the North Carolina Quit Line.
9 Gaps = Opportunity What I want you to see is not only are these risk factors highly prevalent to North Carolina, but there s a long way to go to achieve control. And, so, the use of aspirin and ischemic heart disease we re only about half-way there in terms of hypertension control for our full population of patients, we re only about half-way there. To meet lipid control recommendations, we re only about a third of the way there. And we only do documented smoking cessation counseling in about a quarter of our patients. And, so, the idea of intensification within the practice itself, getting patients to adhere to their medicines better, and using the lifestyle resources that are available in the community. These are all things we can do to close this gap.
10 Risk factors are graded, thus risk reduction on several fronts can improve outcomes This figure is a depiction of what we can achieve by controlling these risk factors. And as you can see, you get a benefit even if you just control one risk factor in terms of cardiovascular mortality, specific heart attack mortality, and all-cause mortality and with each factor that s controlled per patient, there s a linear benefit that accrues.
11 Practice Transformation So, we ve talked about the benefits to your patients, and those benefits really win the day. But there are also benefits to your practice. First of all, we ve heard about Medicare transitioning to value-based care at least 50% by 2018. And using some sort of pay-for-performance criteria, again as much as 80% by 2018. So, value-based care is coming down the pike, and your practice needs to be prepared. And we can help get you there. Practices, then, can also learn through this project to use advanced analytics to maximize good outcomes for their practices and maximize again the value of care. And we can also help practices learn to do population health management for, again, not just for the patients that are in front of you, but for all the patients who are part of your patient panel.
12 Heart Health NOW Other benefits for the practice include having onsite practice facilitators visit you and work with you to, again, achieve these goals that we ve already talked about. For no cost to the practice, the practice will get sophisticated dashboards on these hearth health measures, analytics including work clothes and use cases; so, again, you ll learn to use data to both improve care and improve the way that things are organized onsite. Also, available to practices will be physician expert consultation on clinical directions and building systems. And this physician expert consultation will be available through one-on-one encounters, through learning collaboratives that will be available to you, and also Webinars that will be available from time to time.
13 Heart Health NOW I talked a little bit about practice facilitation and, again, practice facilitators are basically quality improvement coaches that work with you to try and achieve targets that you and your practice sets. And, so, some of the actual functions that these facilitators can do include just in general looking at the work clothes of your practice and analyzing these. They can help the practice think through tasks to maximize both efficiency and outcomes, and they can help apply quality improvement techniques, for example, using data to perform small tests of change and, then, take successful results from these mini tests and bring them to scale throughout the entire practice organization.
14 Practice Transformation What else do practice facilitators do? They can introduce the practice to informatics approaches, that identify patients at the greatest risks whether they re in the office or not. They can help practices design care to take these at-risk patients and develop a way to engage and reengage them to modify this risk quickly. And they can help work on important issues that either weigh on or simply excite the practice.
15 Heart Health NOW So, another question you might ask is, does practice facilitation really work in reducing cardiovascular risks?
16 Cases: Experiences from NC Primary Care Practices And, fortunately, we ve already had two pilot projects in North Carolina one of which covered 14,500 patients with hypertension, and another reaching approximately 5,000 patients with hypertension.
17 Cases And here s what we found. In the first project that lasted less than a year, 11 of these practices improved hypertension control among their patient population at least 5%. In the second project, you can see the before and after charts here, but starting in the area of the 50ish percent range, these practices went up towards 70% hypertension control for all practice populations. And there has been a study that s shown that if we did this nationally it would save 50,000 lives in one year. So, you re talking about over 1,000 lives if we do this across North Carolina.
18 Reporting This slide is an example of one of the dashboards. And this is the dashboard for risk calculation. Again, this is 10-year risks. And, so, practices can receive a list of all their patients from highest risks to lowest risks, and as you look from left to right across the dashboard, you actually get an indication of what risk factors are well-controlled and which ones aren t. So, at the top you can pick out the patient at the highest risks right away. And, then, you can look to the right and find the risk factor that has to be attenuated right away.
19 Advancing Heart Health in NC Primary Care So, in looking at a couple other questions that I ve encountered as I ve traveled across these state, one question is, can practices that are either already in accountable care organizations, or who will soon by joining accountable care organizations, can these practices participate? And the answer is an unequivocal yes. And the second question, again, I talk to you about the way that a practice facilitator works in a practice. And, so, the other question I get is, can practices work on other work flows, or measures, that are important to the practice with the practice facilitators. And, again, the answer is yes as long as they keep working on cardiovascular risks.
20 Conclusions So, to finish up, again, I want everybody to understand that cardiovascular disease remains the number one killer in North Carolina. Small practices, especially those in rural areas, have very little support to identify high-risk patients and intervene in a systematic way. However, with Hearth Health Now, we re using the best of UNC, AHEC, CCNC, and all of you, all of your practices, and all of your ideas. And we re going to organize those to provide support to help you prevent these catastrophic events among people who are your patients, your neighbors, and your friends. The other thing is, we aim to prove that you all can produce great results with the right systems of dissemination and support that can be compared to all these places like Geisinger, and Mayo who have gotten all the national publicity. I know that we can do it, too. Appreciate your attention. And look forward to working with you.
22 Congratulations
23 The Evidence Team 24 The Evidence Team