1. Lisa F. Waddell, MD, MPH Chief, Community Health and Prevention Association of State and Territorial Health Officials October 21, 2015 National Forum for Heart Disease and Stroke Prevention’s 13 th Annual Meeting High Impact Collaborative Initiatives: Lessons from ASTHO’s Multi-State Million Hearts Learning Collaborative

2. Overview  Provide contextual background on who is ASTHO and what is the ASTHO Million Hearts Learning Collaborative  Outline ASTHO’s Learning Collaborative Approach  Describe our Comprehensive Systems Approach  Highlight Examples Demonstrating Impact  Summarize Lessons Learned

3. Background

4. Association of State and Territorial Health Officials (ASTHO)  ASTHO is a national non-profit organization who represents U.S. states, Territories and freely associated states, and D.C. public health agencies  Members, the chief health officials of these jurisdictions  Convene governmental and nongovernmental agencies  Engage clinical and community partners  Leverage and link data to collaborate with public and private payers to drive payment policy reforms  Raise visibility among a broader community of policymakers, funders

5. 5 ASTHO – 20 Affiliates Representing state and local public health expertise

6. ASTHO Million Hearts Learning Collaborative  The Million Hearts Initiative is focusing, coordinating and enhancing cardiovascular disease prevention activities across public and private sectors in an effort to prevent 1 million heart attacks and strokes by 2017 and demonstrate that improving the health system can save lives.  ASTHO’s Million Hearts Learning Collaborative aims to assist state health agencies in achieving the goal of Million Hearts by supporting state and local health agencies in successfully integrating efforts with health care partners to control blood pressure.  ASTHO is leading a learning collaborative with several states. These states are using a quality improvement process to partner across sectors including clinical, community,public health and others to implement practices and policies to identity, control and improve blood pressure.

7. Million Hearts Learning Collaborative Project Goals:  Improve hypertension control and to achieve the national Million Hearts goal.  Identify and build networks and cross-sector partnerships to control hypertension.  Test models for collaboration between public health and health care.  Experience a QI process to affect practice and policy at all levels of the system.  Focus on systems, sustainability and spread. 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.

8. NJ CT MA RI DE MD ME IL IN MI OH WI AL KY MS TN NY PA AZ CO ID MT NM NV UT WY AK CA HI OR GA NC SC VA WV IA KS MN ND NE SD AR OK TX FL LA MO VT NH WA DC KEY Blue = Year 1 states Yellow = Year 2 states Green = Year 3 states Learning Collaborative States, Territories and Freely Associated States

9. The Approach

10.  Secured CDC funding and federal support  Engaged multiple partners  Selected states and provided grant funding  Leveraged state health department leadership  Required Multi-Stakeholder Team  Identified levers for health systems change  States conducted Multi Partner Assessments  Supported States in using Rapid PDSA  Provided Technical Assistance  Facilitated In State Stakeholder Meetings  Facilitated Virtual Multi-State Learning Sessions  Hosted All State/Partners Meetings in D.C. or Atlanta

11. Million Hearts Collaborative State Team MembersNational Partners State Health Agency lead Senior Deputy Public or Private Health Plan Local Health Department Clinical Provider Community Partner Health IT Expertise Regional Partners Health Equity/Diversity Expertise QIO or Community Health Center Networks American Heart Association Association of Health Insurance Plans Association of Public Health Nurses National Association of Community Health Centers National Association of Chronic Disease Directors National Association of County and City Health Officials National Forum for Heart Disease and Stroke National Association of Medicaid Directors YMCA of the USA

12. Comprehensive Systems Approach

13. Communication Systems Change Video: http://youtu.be/PJsgZZIjoHk Leadership and Vision

14. Five Key Levers for QI Driven Impact National, State, Local Leadership & Partnership Engagement Community and Clinical Resources and Linkages Data-Driven Action Standardized Protocols Financing and Policy Approaches

15. Comprehensive Systems Approach

16. Leadership & Vision Partnerships Communication Data & Evaluation Multi Partner Assessment Evidence- based & Best Practice: Strategies for Identifying, Improving, & Controll ing Hypertension Outcome: Reach Aim Statement

17. The IMPACT

18. State Impact: Number of People Reached Current: 276,676 Potential: 3,341,215 From just 5 states - Identified 5,632 individuals with HTN - Referred 2,556 (45%) of these individuals to services - 201 individuals with HTN reduced their BP and 154 achieved BP control In Year Two Years with 16 States: Over 430 PDSA Pilot Cycles 12 Multi-State Meetings 84 Peer Group Virtual Convenings Over 290 partners and stakeholders (payers, hospital systems, QIOs, FQHC’s, local public health, community partners, state public health, health informatics, paramedics, medical reserve corps and other non-traditional partners) working together State Systems Change Leading to Real Change NJ CT MA RI DE MD ME IL IN MI OHOH WI AL KY MSMS TN NY PA AZ CO ID MT NM NV UT WY AK CA HI OR GA NC SC VA WVWV IA KS MNMN NDND NE SD AR OK TX FL LA MOMO VT NH WA DC KEY Red = Continuing states Dark grey = New states

19. Community-Clinical Linkages  Ohio’s Summit County is using the County Health Department to coordinate patient care, connecting providing, public health and community resources.  Engaged 11 practices and developed practice specific QI plans to improve BP  Establishing community based referral mechanisms to public health care coordination services  Arkansas has partnered with clinicians to provide community team-based care for patients with uncontrolled HTN

20. Data-Driven Action Illinois: Using hospital discharge data to inform standardized community wide BP screening and referral protocols

21. Standardizing Clinical Protocols NH published a 10-step manual documenting clinical care protocols10-step manual MN’s four participating clinics have developed protocols addressing accurate BP measurement, home monitoring treatment, follow-up and referrals. These are being incorporated into additional 15 clinics and will be expanded to also address diabetes. OK has developed a protocol for identifying and referring individuals with HTN into a public health nurse driven care coordination system

22. Financing and Policy OK is partnering with BlueCross BlueShield (OK) to test a pay for performance system that reimburses for care coordination, pharmacy, and community based services based on hypertension outcomes. NY is looing at the adoption of a 90 day pharmacy benefit across all Medicaid Managed Care plan MI is exploring policy changes to support reimbursement of CHW’s

23. Systems Changes  DC is using EHRs to identify patients with undiagnosed HTN; initiate f/up and referral to community resources  The health agency is partnering with 20 health centers and hospital systems to implement protocols to conduct f/up visits using non-physician health care team members. These protocols are embedded in their EHR’s.  Created shared practice agreements and are embedding referral protocols into EMRs. In Year 1, 3962 undiagnosed patients have been identified across 20 health centers  VT is examining Medicaid, BCBS (VT) and other claims data to identify patients (Patient Registries) with HTN and assess medication adherence. Using the data to develop a statewide “heat map” of HTN prevalence.  Scheduling f/up appointments for all patients  Standardizing BP measurement technique training  Connecting patients with community resources

24. Key Lessons Learned

25. Lessons Learned  Learning Collaboratives are effective public health tool to address complex systems changes and rapidly spread changes  Engaged leadership and multi-sectorial partners are key  Leveraging technology is an important tool to facilitate state to state learning  Rapid Cycle QI PDSA Cycles can produce quick and impactful results  Partnerships developed through this Learning Collaborative enhance sustainability

26. Resources, Examples, and State Information ASTHO’s Million Hearts Tools for Change website www.astho.org/Million-Hearts

27. Thank You Contact Information lwaddell@astho.org eromero@astho.org lshaull@astho.org lwaddell@astho.org eromero@astho.org L