A Team-Based Approach to Hypertension Control Emily Kosirog, PharmD, BCACP Assistant Professor, Clinical Pharmacist University of Colorado Skaggs School of Pharmacy Salud Family Health Centers

Outline Background Overview of Salud Family Health Centers and Clinical Quality Team Description of Interventions Results Future Plans

Background Hypertension control is essential to prevent heart attacks, strokes, and other serious, life-threatening conditions Hypertension and hypertension complications disproportionately affect low-income and minority patients Controlling Hypertension includes many parts of the patient care process Documentation Education Measuring technique Prescribing https://bphc.hrsa.gov/uds/datacenter.aspx?q=d&bid=080130&state=CO&year=2016 Hypertension-related hospitalizations cost the US billions of dollars annually The CDC/AHA “Million Hearts” Campaign recognizes clinics as “Hypertensions Champions” if blood pressure is controlled in ≥70% of the population for at least 1 year

Salud Family Health Centers

Salud Family Health Centers Federally Qualified Health Centers 12 clinics in Northeastern Colorado Over 76,500 patients seen in 2016 66% racial or ethnic minority 34% best served in another language 90% below 200% Federal Poverty Level Commerce City Clinic Largest Salud Site 13 full-time medical providers 4 behavioral health providers + trainees 2 clinical pharmacists (1 FTE) + trainees In-house pharmacy, imaging, dental clinic https://bphc.hrsa.gov/uds/datacenter.aspx?q=d&bid=080130&state=CO&year=2016

Salud Clinical Quality Teams Salud Reports Uniform Data System (UDS) Measures Quality Teams manage quality for UDS, Meaningful Use, and other projects as needed Clinical Quality Teams are Site-Specific Commerce City Quality Team Center Management Director Medical Assistant Manager Front Desk Manager Behavioral Health Provider Clinical Pharmacist Medical Director Dental Director Liaison from Salud Administration Quality Team As needed: Front line staff, dispensing pharmacist, etc.

Hypertension Clinical Quality Blood pressure control defined by UDS as BP <140/90 in patients diagnosed with hypertension who are 18-85 years old Exclusions: pregnancy, end-stage renal disease, dialysis In 2016, 22% of patients cared for at Salud Family Health Centers had a diagnosis of Hypertension. 61% had a Blood Pressure <140/90 Salud is targeting 67.5% control in 2017 Azara Clinical Quality Tool utilized to evaluate real-time quality measures Salud is out-performed by most peer FQHCs

Identifying the Problem For the past year, CC Salud has hovered between 60-62% Hypertension Control. Green Line= Salud Target Blue Line = Commerce City Quality

Reviewing the Data Data pulled a little after the start of the project when we felt we needed more information…more than half of patients with Uncontrolled BP were within 10 points of their goal!

A Team-Based Approach Many Care Team Members played a vital role in this project Customer Service Associates- CSAs (Front Desk) Medical Assistants Providers Clinical Pharmacists Every member of the patient care process played a vital role in this project!!

Methods Education: In January and February of 2017, PGY2 Pharmacy Resident refreshed Medical Assistants on proper blood pressure measuring technique Documentation: Providers were trained on appropriate documentation of blood pressure Outreach: In April 2017, CSAs were provided a list of patients with hypertension who had a blood pressure of >140/90 at their last clinic visit and reached out via phone call 3 pronged approach

Education of Medical Assistants

Education of Medical Assistants

Education of Medical Assistants

Documentation Utilize e-clinical works (eCW) EHR Different places to document multiple blood pressures Every provider/MA did it differently!

Outreach to Patients CSAs divided into 3 “pods” Each pod has 3-4 providers Each pod provided with an Excel spreadsheet of patients who had elevated blood pressure at the last visit Separated patients into those who had been seen within 6 months, and those with no appointment for 6 months Offered an appointment with provider to re-check blood pressure Script Provided in English/Spanish Outcome of phone call documented

Script “Your doctor is worried about your blood pressure. It was high at your last visit. This puts you at high risk for heart and kidney problems in the future. Your doctor would like you to come back to clinic to check your blood pressure, would you like to make an appointment now?” If patient replies no, encourage them to schedule a visit at their earliest convenience. Contact attempted 3 times, if no response, a letter was sent.

Overall Outcomes Outcome N (%) Total Patients on the list 760 Patients who received outreach 549(72) Patients who agreed to schedule 267 (49) Patients seen as of May 30th 198 (75) Billable Visits as of May 30th 268 Patients with BP <140/90 at most recent follow-up 130 (66) These lists were pulled later than our initial analysis lists, hence why “n”s may differ

at most recent follow up visit Overall Outcomes 760 Patients with BP >140/90 72% (549) Outreached 49% (267) Scheduled 268 Billable Visits 75% (198) Seen 66% (130) with BP < 140/90 at most recent follow up visit

Overall Outcomes

Improvement Red & Yellow Pod Outcome n Total Patients on the list 523 Patients who received outreach Patients who agreed to schedule 258 Patients seen as of May 30th 135 Billable Visits as of May 30th 253 Patients with BP <140/90 at most recent follow-up 124/189 61% Controlled 68% Controlled

“Accidental Control Group” Improvement Blue Pod Outcome n Total Patients on the list 237 Patients who received outreach 26 Patients who agreed to schedule 9 Patients seen as of May 30th Billable Visits as of May 30th 15 Patients with BP <140/90 at most recent follow-up 6/9 65% Controlled 68% Controlled

Overall Outcomes Probably due to outreach Probably due to training

Lessons Learned Reasons patients weren’t scheduled 211 patients weren’t called- 28% “Other”- 127/549 patients (23%) Usually patient moved or phone disconnected “Letter Sent”-104/549 (19%) CSA called 3 times without reaching patient Patient Declined-49/549 (9%) Patients seen >6 months ago were less likely to be reached or to schedule follow-up

Goal: Maintain controlled blood pressure for the population Future Direction Goal: Maintain controlled blood pressure for the population Hypertension control will likely decrease in the future New patients Staff turnover

Future Direction Project should be repeated every 6-12 months Educate: Implement a short, every 6 month quiz for Medical Assistants on blood pressure technique Document: Remind Providers and Medical Assistants proper blood pressure documentation Outreach: Repeat CSA phone outreach Focus on patient populations most likely to return for a visit, like those seen within the past 6 months

One Last Update… BLOOD PRESSURE CONTROL <140/90 Pulled Friday 6/23

Questions? Special Thanks Natalia Uzal, PharmD Natalia was a PGY2 Ambulatory Care Pharmacy Resident at the time of this project and did the majority of the education and training for our front-line staff Without Natalia's enthusiasm, this project would not have been as successful! Questions?