Blood Pressure Control: Path to the Million Hearts Award Jessicca Moore, MSN, FNP Associate Clinical Director Nurit Licht, MD, Chief Medical Officer
The Million Hearts Program Started in 2011, a national initiative to prevent 1 million heart attacks and strokes in 5 years CDC co-leads Million Hearts with the US Department of Health and Human Services, Center for Medicare & Medicaid Services The 2015 Hypertension Control Champions used evidence-based strategies and patient engagement to help their patients achieve blood pressure control rates at or above the Million Hearts target of 70 percent The 18 Champions, ranging from small practices to large health care systems throughout the U.S., provide care to nearly 1.5 million adults, Petaluma Health Center was named a 2015 Million Hearts Champion To be eligible, entrants shared verifiable high blood pressure control data and highlighted successful strategies and best practices adopted by the practice or system, such as the use of health information technology and team-based care All Champions achieved control rates of 70 percent or greater for their adult patients by using a variety of approaches, including: Making high blood pressure control a priority Using evidence-based treatment guidelines and protocols Using health care teams to increase the frequency of contact with patients Implementing consistent, strategic use of electronic health records that include clinical decision support tools, patient reminders, and registry functionality Staying engaged with patients by offering free blood pressure checks and implementing the use of a patient navigator or care coordinator
Understanding the Problem: Education and Understanding Patient s Voice Many patients with hypertension and uncontrolled blood pressure do not understand the impact on their health Advisory Council Informal Interviews Staff/Provider Voice Workgroup Team Meetings
Understanding the Problem: Team Approach Patient s Voice Getting blood pressure under control requires multiple interventions and visits Advisory Council Informal Interviews Staff/Provider Voice Workgroup Team Meetings
Understanding the Problem: Medication Adherence Patient s Voice Many patients with hypertension and uncontrolled blood pressure are not taking their medication as directed. Advisory Council Informal Interviews Staff/Provider Voice Workgroup Team Meetings
Barriers Identified Systems No Standard Protocol for Treatment No Standard Protocol for Medication Intensification No Consistent System to Address Adherence Pharmacy Refills People Misunderstanding Diagnosis Misunderstanding Treatment Plan Fear of Side Effects
System Solutions Standard workflow with templates to support asking about issues such as adherence Standard education for patients Standard process for team roles and visit schedules
Template + Training We had the template, but staff needed training on how to best engage with patients to get meaningful and accurate information? Many people with high blood pressure sometimes forget to take their medication. How often do you forget or skip your medications? Tell me how you take your medications. What s your goal for your blood pressure?
Standardization Standard HTN protocols for providers and RNs to follow Standardized patient education
Refill Solutions: Hassle Free Standard 90 day supply for chronic medications with 3 refills Add text to sig. Lisinopril-HCTZ 10/25 one tablet daily for blood pressure Stop using refills as the gate-keeper Say yes AND follow regular recall calendar In house pharmacy for more seamless communication
Results 2013-2016
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CONTACT INFORMATION Jessicca Moore, MSN, FNP jessiccam@phealthcenter.org Nurit Licht, MD nuritl@phealthcenter.org