Hypertension Best Practice Session 1 Informational This is the first of six sessions for the Hypertension Best Practice model of care.

Session Outline Better Health Partnership Overview Hypertension (HTN) Facts Hypertension Best Practices At the end of this session --- Hypertension Best Practice #1 ----you should be able to: explain who Better Health Partnership is and what they do. state some key facts about hypertension list the elements of the Hypertension Best Practice model of care and begin to apply them over the next several months to improve blood pressure control for your patient population.

Better Health Partnership Better Health Partnership overview In slides 3-6, we describe our organization to the clinic personnel. If you are from a different organization working with a clinic, this is where you can introduce your organization or you can delete these slides if the practice knows you. If you are working with Better Health Partnership, you can say the following with this slide: We will begin our session with a video clip about Better Health Partnership.

Better Health Partnership Regional health care improvement collaborative funded by grants and memberships Mission: To provide a safe place for competitors to collaborate to drive better health Vision: To help make Northeast Ohio a healthier place to live and a better place to do business Publicly report quality of care on over 191,000 adults seen by 717 outpatient primary care clinicians in 9 health care systems Read the slide. Regional health care improvement collaborative funded through grants and health care system membership. Mission: Where collaboration and competition come together; Bringing data and insights from all to drive better health care. Vision: To help make Northeast Ohio a healthier place to live and a better place to do business. Publicly reports the quality of care on over 191,000 adults seen by 717 outpatient primary care clinicians in 9 health care systems in our region.

Learning Collaboratives This is a picture taken at one of Better Health Partnership’s twice a year Learning Collaboratives. These Learning Collaboratives have sessions designed to enhance health care performances of clinicians, and staff. These sessions offer continuing medical education credits (CME) and are an opportunity to network and learn from each other. Best practices are shared and successes are celebrated.

Learn More betterhealthpartnership.org You may learn more about Better Health Partnership by going to their website.

Hypertension Facts Now that we know a little about Better Health Partnership let’s review some facts about hypertension.

Hypertension (HTN) 1 in 3 Americans have high blood pressure HTN leads to heart disease and stroke (leading cause of death in U.S.) & 1,000 deaths per day 46% of Americans with HTN do NOT have good BP control Minorities and those with low SES have greater complications and more deaths Read slide with facts related to hypertension. 1 in 3 Americans have high blood pressure. High Blood Pressure leads to heart disease and stroke (leading cause of death in U.S.) & 1000 deaths/day. About half of (46%) all Americans with hypertension do NOT have good BP control. Minorities and those with low Social Economic Status (SES) have greater complications and greater deaths. Reference: CDC websitehttps://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm. Accessed 02-09-2017

Prevalence of HTN in adults 18 and over in the United States, 2011-2014 When we look at this graph we see the prevalence of hypertension Hypertension is defined as: a systolic blood pressure greater than or equal to 140 mmHg or diastolic blood pressure greater than or equal to 90 mmHg, or the person is currently taking medication to lower their blood pressure, This graph is from the CDC. It shows the prevalence of hypertension for adults 18 and older in the United States: 41.2% of the black population have a prevalence of hypertension Whites are at 28% Hispanic are 25.9% and Asian population is 24.9% Our graph from the CDC also gives a comparison of the prevalence of HTN for both men and women and we see black women have the greatest prevalence of HTN. Reference: CDC website http://www.cdc.gov/nchs/data/databriefs/db220_fig2.png. Accessed 10-27-2016

Prevalence of controlled HTN in adults 18 and over in the United States, 2011-2014 This graph shows the control of hypertension for adults 18 and over in the United States. We see: Whites have the best control of their blood pressure with 55.7% Follow by 48.5% for the black population then Hispanics at 47.4% then Asian at 43.5% Hypertension control is defined as a systolic blood pressure less than 140 mmHg and diastolic blood pressure less than 90 mmHg Reference: CDC website http://www.cdc.gov/nchs/data/databriefs/db220_fig2.png. Accessed 10-27-2016

Blood Pressure Control in Northeast Ohio On this slide, you could show (if available) what the disparities in blood pressure control are currently in your region. We did this to show the importance of working on BP control in our region in clinics serving low income minority populations. When we started this program, there were greater disparities in BP control than currently exist. Here is an example of what we said when we showed this graph. We transitioned from the national data to the regional data by saying the following. While national disparities in BP control exist, we also have pronounced disparities locally. This is a graph of blood pressure control in the Cleveland Area by insurance, income, education and race. We can see by this graph– low education, low income, uninsured African Americans have the “poorest” blood pressure control. This ties in with our HTN facts from slide # 8 where those with the lowest social economic status have greater complication and greatest death from hypertension. Source: Better Health Partnership 2014 data

BP Control (Your Practice vs. Others) The practice should add data for their clinic to this slide as well as data for their region if they are not in Cuyahoga County The practice should discuss their results with a focus on the following points: How does their data compare with CDC ‘s report and/or their local results. Practice discuss what they discovered “today” by looking at their data.

Hypertension Best Practice

System changes may work best (Yes, it’s a urinal) Share this humorous but effective quality improvement story about a urinal in Amsterdam. This is a picture of a urinal in the Amsterdam Airport. You see, the airport was having trouble with “spillage” in the men’s bathroom. The men did not always get all of their urine in the urinal; some went on the floor. A Dutch maintenance man, Jos Van Bedoff, proposed to the airport board of directors that they etch flies in the urinal because guys (apparently automatically) want to directly aim their urine at a target. Once this innovative idea was implemented, the Amsterdam Airport reported to have reduced the spillage of urine by up to 80%, and decreased their cleaning cost by 20% or more. Source: https://worksthatwork.com/1/urinal-fly accessed 11/1/16. Don’t ask us how this urine “spillage” decrease was measured. We share this story to emphasize two things: how a system-level change makes it easier to improve an outcome than expecting individual level behaviour change, and how important it is to have a target for quality improvement (in this case hypertension).

HTN Best Practice Key components Education on accurate BP measurement Timely follow-up Standardized treatment algorithm Outreach using EMR-based patient registries Communication curriculum for building trusting relationships with patients We are going to move toward making changes in our system to help establish better blood pressure control. Our Hypertension best practice model has 5 components. Accurate blood pressure measurement. We found inaccurate BP readings contribute to false BP elevation and sometimes overtreatment. We will show you a video in session 2 about how to take the blood pressure correctly. Taking an accurate BP also includes getting a 2nd measurement when the first blood pressure is greater than or equal to 140/90 Monthly follow-up visits with a nurse or MA until BP is controlled A treatment algorithm which prioritize once daily low cost meds as patients will be more adherent with their medication if they treatment regime is easy to follow and they can afford the medication. Conducting outreach to patients whose last BP was elevated and who do not have a scheduled follow-up visit within 30 days Building trusting relationships with patients (after undergoing a communication curriculum focused on empathy, health literacy and implicit bias) Adapted from Jaffe et al. Improved Blood Pressure Control Associated With a Large-Scale Hypertension Program. JAMA 2013; 310(7): 699-705.

Clinics improved BP control up to 13 percentage points in one year after implementing the HTN best practice. We show this graph to give you an idea of the success of system changes in implementing a HTN Best Practice model of care in safety net clinics. Each bar on the graph represents a primary care clinic. The top performers on the graph improved between 5 and 13 percentage points over 1 year. These top performers implemented the HTN Best Practice model of care. We de-identified the practices names for confidentiality.

This graph demonstrates that the greatest improvements in BP control were seen in Medicaid enrollees, minorities, low education and low income populations. These populations improved the most since we were targeting safety net clinics with our intervention strategies.

Assessing Practices’ Process Do you routinely obtain a repeat BP measurement if the first BP is elevated? Do you routinely schedule follow-ups for all patients with elevated BP within one month? Have you had any sessions on communication? Do you have a treatment algorithm? Let’s discuss our current process for hypertension management. The facilitator should ask the practice to briefly describe what their process for checking patients blood pressure. The facilitator may want to observe the actual process. Facilitator leads the discussion with the following questions: Do we recheck BPs if they are elevated? Who rechecks the BP if it is elevated ? Where and how is the second BP reordered? What is our process for scheduling a follow up appointment if the BP is elevated? How often do we have the patient to return for a BP check if it is elevated? Who are they schedule with if their BP is elevated (clinician, MA or nurse)?

Disclaimer Use of these slides alone will not improve BP control rates in your practice. Higher BP control rates will be achieved if active quality improvement efforts are deployed in conjunction with these tactics. Practice coach consultation is available to assist you in improving outcomes.

Acknowledgements This work is made possible with funding from: The Mt. Sinai Health Care Foundation Centers for Disease Control and Prevention Special thanks to: Better Health Partnership participating clinics Health Improvement Partnership-Cuyahoga (HIP-Cuyahoga)

Contact Info For questions about the online toolkit or assistance with implementation, please contact our coaching team: info@betterhealthpartnership.org

Discussion/Questions? Thank you Discussion/Questions?