Hypertension Best Practice Session 3 Timely Follow-Up and Continuous QI This is the third session for Hypertension Best Practice.

Hypertension Best Practice Elements BP measurement: include two BP readings if first is high (≥140/90 mmHg) Timely follow-up: monthly visits until BP controlled Treatment algorithm: low-cost, once-daily meds Communication: building trusting relationships Outreach: using a registry Lets review the elements for Hypertension Best Practice that we will be discussing today. Read the elements highlighted in red on the slide.

Hypertensive Adults with Elevated Blood Pressure Place your data on this slide for the percentage of patients you have in your practice with an elevated BP (>140/90). Review that this is what we are trying to improve (lower is better) although we may not see improvement until we have improved the elements of the best practice such as percent with a repeat blood pressure and timely follow-up for many months in a row. You should gather data for several months.

Two BP Readings When 1st Elevated Place the clinic-level data on this slide for the percentage of patients you have in your practice who had a second BP reading during their office visit if their BP was elevated (BP >140/90mmHg). Once the clinic has had a chance to review their numbers, move to the next slide to see what further improvements can be made. You should gather data for several months.

Two BP Readings When 1st Elevated What is the current process? How is it working? Refine goal for repeat blood pressure readings. What action(s) will it take to achieve the goal? This is an opportunity for you and your staff to discuss your current process for getting a second BP reading when the first BP reading at the same office visit is elevated. Have your staff reflect on the correct technique for taking blood pressures (from session # 2). i.e. patient setting with feet flat on floor and not talking, correct BP cuff size and arm bare (no sleeves rolled up) If your practice is not at 80% or better for the second BP reading measurement, then develop a quality improvement plan to improve repeat BP reading. Discuss actions the staff will take to reach repeat BP goal, and share best practices of what has worked at other clinics.

Timely Follow-up and Nurse/MA-led visits

Timely Follow-Up Process Process to ensure follow-up is scheduled within one month (with nurse or provider), when repeat BP still is elevated. Discuss what the practice’s current process is for scheduling patients for a follow up visit if their repeat BP remains elevated. Timely follow up will be covered in more detail in session #3. This slide is placed here to create an awareness around the importance of timely follow up and effective BP management/control.

Timely Follow-up Place your data on this slide for the percentage of patients you have in your practice who had a follow up appointment with the nurse, MA or provider within 30 days if their BP was elevated (BP >140/90mmHg). You should gather data for several months but you may only have baseline or 2 months worth of data when first beginning to work with the practice. If your results are less than desirable implement, a QI plan to improve this measure should be discussed.

Timely Follow-Up Process What is the current process? How is it working? Develop a goal for scheduling timely follow- up visits. What action(s) are needed to achieve the goal? Timely follow up is a very important piece of the HTN Best Practice program. It entails making sure patients receive a follow up appointment for blood pressure check within 30 days if their BP is elevated (> 140/90). Discuss your clinic’s process for scheduling a nurse or Medical Assistant (MA) led blood pressure visit. Your clinic may need to develop a template for the nurse/MA to record the results of the visit. You can also schedule a patient back with the provider within one month. However, preference is placed on nurse/MA led visits since it reduces cost and wait time for patients.

Sample RN/MA HTN Follow-up Visit Referral Process This is an example of a work flow one of the clinics we worked with developed. Another best practice was to have the MA who took the repeat blood pressure automatically schedule a nurse visit if the BP reading was elevated. This way, no one forgot at the end of the visit.

Nurse or MA-led Appointment Nurse visit template Review common BP meds and side effects Review DASH diet Patient educational brochures First review the nurse visit template document in detail with the practice. Go through each question. They should review, modify, and finalize the template prior to the next session. During the nurse/MA led visit it is important to review current medication and confirm that the patient is taking the medications as prescribe. Ask the patient to tell you how they are taking their medication. Alert the provider to any discrepancies. Discuss the DASH diet (Dietary Approaches to Stop Hypertension) or a low salt diet with your patient. Help the patient to set goals for dietary management. If you have a DASH diet or other low salt diet information you will want to provide them to the patient during the nurse/MA visit. Provide your patient with educational material and tools for self management i.e. a log to record their blood pressure.

Observation Feedback Complete staff observation using a checklist, and provide feedback Quality and competency checks are important for the HTN best practice. We encourage observation and feedback for assisting practices with workflow redesign. You may develop your own observation checklist or contact Better Health Partnership (info@betterhealthpartnership.org) for further assistance. Any global feedback you have from these forms can be added here to discuss with the practice or discussed separately.

Treatment Algorithm

Treatment Algorithm Review and finalize treatment algorithm. Here is where you would review and finalize the treatment algorithm that you discussed briefly during session 2. If they plan to use the example algorithm, that is great. If they want to adapt the algorithm, then confirm it matches the most current evidence-based guidelines from the Joint National Commission or American Heart Association.

Review Next Steps Second BP measurement Timely follow-up process to schedule HTN follow-up visits Discuss next steps for each of the two process measures you are trying to improve.

Disclaimer Use of these slides alone will not improve blood pressure control within your practice. Blood pressure control will be achieved through active quality improvement efforts in conjunction with these slides. Practice coach consultation is available to assist you in improving outcomes.

Acknowledgements This work was made possible with funding from: The Mount Sinai Health Care Foundation U.S. 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?