Hypertension Best Practice Session 6 Implicit Bias

Hypertension best practice elements BP measurement: include 2 BP readings if first is high Timely follow-up: monthly visits until BP controlled Treatment algorithm: low cost once daily meds Communication: building trusting relationships Outreach: using a registry Read slide to review the elements of HTN Best Practice

Learning objectives Review process for obtaining a second blood pressure reading and sustaining efforts Review process for timely follow-up and sustaining efforts Finalize a plan for outreach using HTN registry Understand the importance of implicit bias as it relates to communicating with patients Read slide to share the objectives with the staff. Ask your team to commit to sustaining the gains the practice has made.

Data Review Facilitator will need to review the clinic’s data for the previous month.

Uncontrolled blood pressure, by month Place your data/graph here. It is important for all members of the practice to know how well they are doing and see opportunities for improvement. Share with your team the practice’s data for blood pressure control. Insert graph of percent of adults (≥ 18 years old) with hypertension on the problem list and seen in the last month where blood pressure is ≥ 140/90mmHg. LOWER is better

Two BP readings when first is elevated Place your data/graph here. Insert data for your clinic for the last few months. Percent of adults with hypertension and elevated blood pressure seen in the last month with two blood pressure readings if the first reading was elevated (≥ 140/90 mmHg) HIGHER is better If your practice does not have 80% of your patients with an elevated BP receiving a second BP you will want to discuss your current process and revised an action plan to improve these results. You will want to evaluate workflows, utilize BP alerts in your system or some other sort of flagging/reminder system.

How could we increase the rates of repeat BP to 80% or higher? Discuss concrete ways your practice can increase the repeat BP measurement. Set stretch goals and have all team members involve in the planning and implementation process. If your repeat BP measure is 80% or better, then discuss ways in which the practice can sustain and/or improve on this measure. Remember: Once progress is made you want to have systems/workflows in place to maintain any gains made. Discuss how this expectation can be incorporated into new employees training.

Place your data/graph here. Timely follow-up data Place your data/graph here. Percent of adults with hypertension and elevated blood pressure (≥ 140/90 mmHg) seen in the last month with a scheduled follow-up in the next 30 days. Include several months of data. For this graph, HIGHER is better.

Timely follow-up process How could we increase one-month follow-up rates to 70%? Discuss concrete ways your practice can increase the timely follow up measurement. Set stretch goals and have all team members involve in the planning and implementation process. If your repeat BP measure is 70% or better, then discuss ways in which the practice can sustain and/or improve on this measure. Remember: Once progress is made you want to have systems/workflows in place to maintain any gains made. Discuss how this expectation can be incorporated into new employees training.

Outreach

Outreach Outreach criteria Adults seen by the clinic within the past 2 years with the last BP recorded as elevated. Outreach methods E-mail Patient health portal Postal mail Telephone call and/or secure text messaging Discuss your clinic’s process for conducting outreach. Determine which patients staff will outreach to and how often you will schedule an outreach. Discuss outreach methods and the effectiveness of each method. Outreach Methods E-mail Patient health portal Direct e-mail and text messaging

Sample process for outreach Attempt to contact patient 3 times Here is a sample process flow for conducting outreach.

Communication

Communication outline Implicit bias video and discussion Discuss implicit bias homework Strategies to reduce bias Facilitator tells the team that the communication portion of session 6 consists of: Watching a video on Implicit Bias followed by a brief discussion of their reactions to the video. Discussing the implicit bias homework and Discussing strategies to Reduce Bias.

Video Silent Beats Watch the video then ask staff to provide their feedback to the video “Silent Beats.” Questions or thoughts for discussion may include: What stood out the most for them? How does the video apply within their clinical setting?

Reactions to the homework Next we will discuss our homework. We were to take 1 or 2 of the Implicit Biases tests. Have staff/providers describe the test and discuss their feelings about the test. Ask them if they agree or disagree with their results and why or why not. Ask if anything surprised them about the test. Staff/providers do not have to specifically disclose their test results. Ask staff/providers to share what they might do as a result of their test discovery.

Implicit bias evidence Greater implicit pro-White bias associated with lower referral for thrombolysis in Black vs. Whites. (Green, 20071) Overweight/obese individuals more likely to report negative health care experiences and to avoid, cancel, or delay medical appointments than healthy weight peers. (McCauley, 20152) Despite being otherwise identical, male patients are referred for TKA more often than females. (Borkhoff, 20081) No association between implicit bias scores and medication intensification for blood pressure. (Blair, 20143) Likely due to use of best practice protocols Read the slide which shows evidence that implicit bias impacts health and healthcare. Discuss the findings and how relevant this is today to improving health outcomes. 1. Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities. J Gen Intern Med 2013; 28(11):1504–10 2. McCauley J. An Examination of Weight, Weight Bias, and Health Care Utilization and Attitudes Among Emerging Adults. 2015. Available at: http://scholarscompass.vcu.edu/cgi/viewcontent.cgi?article=4988&context=etd 3. Blair IV, Steiner JF, Hanratty R et al. An investigation of associations between clinicians' ethnic or racial bias and hypertension treatment, medication adherence and blood pressure control. J Gen Intern Med. 2014 Jul;29(7):987-95.

Strategies to reduce implicit bias Best Practice Protocols For example, HTN best practice Environment to reduce negative experiences For obesity: chairs without armrests, scales that obese patients can use easily, BP cuffs of all sizes readily available, watch language and nonverbal expressions Individuation: detailed history Perspective taking: empathy Increased opportunity for positive contact Have staff/providers discuss strategies they can use to reduce implicit bias in their work environment/current (job) roles. Emphasize the use of evidence based best practices and protocols to reduce bias in delivering care. Look at your clinic and discuss if and how it can be enhanced to reduce implicit bias. Discuss steps an individual can take to decrease stereotypes and replace them with more positive thoughts about others. Long-term reduction in implicit race bias: A prejudice habit breaking intervention. J Exp Soc Psychol. 2012 November; 48(6): 1267–1278.

Next steps Determine who will review data with the practice and at what times to sustain efforts.

Congratulations! Your have completed all six Hypertension Best Practice sessions. Congratulations! Your have completed all 6 of the Hypertension Best Practice Sessions. Please feel free to review any session with new staff or with staff who may have missed a session.

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 Mt. Sinai Healthcare Foundation Centers for Disease Control and Prevention Special thanks to: Better Health Partnership participating clinics Health Improvement Partnership-Cuyahoga (HIP-Cuyahoga)

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

Thank you!