Hiding in Plain Sight: Undiagnosed Hypertension Melissa Barajas Director of Population Health

FQHC founded in health centers in San Diego and Riverside counties 65k patients annually About us Mission Statement: Neighborhood Healthcare is committed to providing quality health care and promoting wellness to everyone in our communities, focusing on those most in need.

Overview 1. Benchmark your HTN prevalence 2. Establish clinical criteria for potential undiagnosed HTN 3. Leverage EHR to find patients who meet clinical criteria 4. Implement a plan for addressing the identified population

Hypertension Prevalence Million Hearts® Hypertension Prevalence Estimator Tool

Hypertension Prevalence Million Hearts® Hypertension Prevalence Estimator Tool

Not Visit Related Before Patient Comes to Office Daily Care Team Huddle Check-in/ Waiting/ Rooming Provider Encounter Encounter Closing After Patient Leaves Office Outside Encounters [Population management] Foundational Work Current Information flow Patient appointm ents are confirmed via phone calls Preventative care reviewed, routine labs/ screening tests are ordered Review last BP readings to indicate if previously elevated Vitals taken by MA. If BP is elevated, MA to recheck in 5 minutes Alert PCP when BP is elevated Address chief complaints/ primary Dx/ procedures if indicated Determine f/u plan, place orders Visit summary given to patient MA ensures an elevated BP readings was addressed with PCP and/or follow up plan in place. Ensure all labs, screening tests, future appointment s are scheduled Sees pts with elevated BP 2 weeks after visit with provider. BP education and med rec. Utilize registry lists to recall patients with elevated BP Other pilots: Pharmacist visit, medication adherence Review and update status at Quality Improvement meetings. Protocol developed for accurate BP recording with treatment algorithms for HTN Staff training on diagnostic BP recording Potential Enhancements Larger focus on motivational interviewing, lifestyle behaviors outside our clinic to empower patients to make healthy choices Ask patient to bring any home BP readings and medicatio ns to visit, wear proper clothing, take BP meds Automatically perform diagnostic BPs if elevated (sitting, standing, etc.) Configure EMR or alerts app to flag if patient has 2+ elevated BP readings and no dx of HTN. Routinely emphasize lifestyle modifications, provide patient education Reiterate lifestyle modifications to improve BP control Refer patients to behavioral health services as needed Recall patients with 2+ elevated readings, no HTN Dx. Phone call check in between visits to see how patient is doing with meds and lifestyle changes. Configure EMR to include HTN medication algorithms Develop standard set of questions for support staff to ask patients if BP is elevated. CDS/QI Approach – Mapping Workflows

Key Foundations Make QI Initiative a Practice Priority Implement Supporting Policies and Processes Staff Training Use Evidence-Based Guidelines and Protocols Population Health Management Use Patient Registries Use Practice Data to Drive Improvement Individual Patient Supports Prepare Patient and Staff for Visit Optimize Intake & Waiting Optimize the Encounter Optimize the Encounter Closing (Checkout) Optimize Supports Outside of Visit Key Foundations

Topic/ Change Idea CategoryQI Change Concept Resources Optimize every opportunity to identify HIPs patients Population Health Management Optimize outreach HTN Outreach Protocol, patient registries Individual patient support Optimize the encounter/ inreach Alerts application Connecting to the Larger QI Picture

InformationPersonFormatChannelWhen in Workflow Patients with elevated blood pressure readings and no HTN diagnosis Health Coaches/ Care Coordinator ProtocolAutomated Patient registries Population health outreach CliniciansAlertsEHR Alerts application At point of service CDS 5 Rights Analysis

Change Idea in Action

2+ visits in last 180 days with BP >140/90, no HTN dx

Undiagnosed Cohort Data, 1 year later Number of patients in denominator with 1+ follow-up visit(s) on or after 2/1/ Number of patients identified as potentially undiagnosed for HTN on 1/31/ Undiagnosed Cohort - Follow-up Visit74.0% Number of patients in denominator who received a HTN diagnosis on or after 2/1/ Number of patients identified as potentially undiagnosed for HTN on 1/31/2015 with at least 1+ follow-up visit 392 Undiagnosed Cohort - Hypertension Diagnosis28.8%

Critical success factors Team work and consistency is key. “ I was just there last week, why didn’t my Dr. say anything?” Versus “That’s right, my Dr. mentioned that last week, thanks for reminding me.” Don’t wait for the patient to show up, go and get them! Resources required Designated Care Coordinator/Health Coach at each site who conducts BP Rechecks and outreach Programmer or EHR capabilities to develop HIPs registry and HIPs alerts Lessons Learned with HIPs

BP Control Run Chart HIPs alert added to EMR Application, CMO notified providers about HIPs cases North San Diego Implemented MTM Pharmacist program with HTN focus HIP registry added to Pt. Care Coordinator workflow to recall patients for evaluation of HTN 2014: Quality Improvement Committee identified BP Control as a priority area. HTN Treatment algorithms and BP Recording protocol implemented -Providers more aggressive on obtaining BP control. Increase in: -Referrals to MTM Pharmacist program for HTN -Referrals to Diabetes management program, BP control also addressed -Pt. Care Coordinators increased focus on recalling patients for BP rechecks HIPs cases entering Hypertension denominator Medicaid Expansion: New patients entering Hypertension denominator n= 8638 n= 9208

BP Control: a closer look BP Recording protocol HTN Treatment algorithms Medication Therapy Management Program PDSA cycles to improve BP control

Study partnership with UCSD and CMMI to make San Diego a heart attach and stroke free zone 4 of our Patient Care Coordinators involved with monthly health coaching for enrolled patients Large focus on medication adherence In north San Diego sites, enrolled patients also receive Medication Therapy Management- a Pharmacist led intervention CMMI Be There campaign Medication Therapy Management

Increase number of health coach visits for blood pressure re-check Larger focus on motivational interviewing, lifestyle behaviors outside our clinic to empower patients to make healthy choices Develop standard set of questions for support staff to ask patients if BP is elevated BP Control: PDSA Cycles

Questions?