1. Global Aim 1 2 3 Assessment Theme Change Ideas Specific Aim Measures SDSA P DS A P D S A P DS A PDSA 1 3 2 We are monitoring a list of 199 patients with hypertension and currently 15% of those patients are within 5 mmHg of controlled blood pressure values; to improve blood pressure measurement and to increase the number of patients with good blood pressure control we are focused on 1) changing care delivery and 2) improving the % of patients with blood pressure control to at least 53% of the population we are currently focused on We aim to improve blood pressure control among patients in the registry we are monitoring for our Medicare Advantage contract. The process begins with the list of eligible patients within this contract with the diagnosis of hypertension and ends with an acceptable blood pressure control depending on age and health status. By working on this process we expect to improve patient outcomes and improve our capacity to develop, monitor, and improve workflows for population health. Microsystem Improvement Progress Initial expectations meeting to meet the team, discuss their current work, goals and ideas for how to develop and improve achieve their year-end goals for several quality measures Initial expectations meeting to meet the team, discuss their current work, goals and ideas for how to develop and improve workflows for population health management within UChicago Medicine beginning with our global risk Medicare Advantage contract and how achieve their year-end goals for several quality measures Blood pressure control Updates made to standard work regarding blood pressure measurement (manual cuff) Updates made to standard work regarding blood pressure measurement (manual cuff) Medical Assistants and nurses have received training on blood pressure measurement and documentation if patient has elevated BP at start of appointment Medical Assistants and nurses have received training on blood pressure measurement and documentation if patient has elevated BP at start of appointment Messages have been sent to PCPs and specialists for upcoming appointment with reminder about blood pressure measurement Messages have been sent to PCPs and specialists for upcoming appointment with reminder about blood pressure measurement We estimate that by mid-December we should have some data to review that will help us understand next steps for care delivery changes and measurement We estimate that by mid-December we should have some data to review that will help us understand next steps for care delivery changes and measurement 12/1/20151/4/2016 Patients Eligible Total CompliantRate Patients Eligible Total CompliantRate Blood Pressure Control1727544%1739253% % hypertensive patients with measurements within 5mmHg above the cutoff (<139/<89)10% % hypertensive patients with elevated SBP between 145 and 152Did not measure11% The team can use this updated data to think about our next ideas and steps for PDSA cycles. We were able to improve the % of patients with BP control between December and January by doing a better job of reaching out to some patients with elevated BP, asking them to come in for BP check, and sending future messages to providers asking them to check BP again in patients who present with elevated BP. We still have other things to roll out and measure which we think can help us have a better grasp of the patients with BP control, 1) MAs have been trained on the BP work we are trying to improve and the new process to check elevated BP but have not started to implement this into their workflow, this will be one area to study small tests of change and understand its impact or the need to change our approach, 2) we also identified another 11% of patients who have slightly elevated BP, and we need to think of some potential areas of intervention that may help us understand poor BP control currently in these patients and ways to improve BP control among these patients. We have a goal to work towards 67% of patients in this population with BP control, and to pick another target for improvement once we reach the goal of 67%.