1. 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

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

3. 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
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

4. Salud Family Health Centers

5. 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

6. 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.

7. Hypertension Clinical Quality
Blood pressure control defined by UDS as BP <140/90 in patients diagnosed with hypertension who are 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

8. 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

9. 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!

10. 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!!

11. 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

12. Education of Medical Assistants

13. Education of Medical Assistants

14. Education of Medical Assistants

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

16. 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

17. 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.

18. 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

19. 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

20. Overall Outcomes

21. 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

22. “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

23. Overall Outcomes
Probably due to outreach
Probably due to training

24. 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

25. 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

26. 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

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

28. 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?