State-Health Plan Collaboration to Improve Blood Pressure in Utah CSG Health Policy Forum on Cardiovascular Health and Wellness Barbara A. Larsen, RD, MPH Program Director, Utah Heart Disease and Stroke Prevention Program September 29, 2006

ACKNOWLEDGEMENTS David L. Larsen, RN, MHA Director, Quality Improvement SelectHealth Joan Ware, RN, MSN Consultant National Association of Chronic Disease Directors Karen Warren, Director of Quality Improvement and Health Education, Molina Health Care Brooke Gardner, BS Utah Heart Disease and Stroke Prevention Program

High Blood Pressure in Utah in 2001/2002 Data: –22.3% of Utah adults report high blood pressure (2001-BRFSS) –59.9% of Utah adults with high blood pressure are taking medication (2001-BRFSS) –59.6% of SelectHealth and 56.9% of Molina patients had blood pressure in control (<= 140/90) (2002) MDs in Utah qualitative data…. –Extremely concerned about cardiovascular health of Utahns –High blood pressure is having detrimental effects on the health of Utahns-at younger and younger ages –Public far underestimates the risks of cardiovascular disease –Patients do not understand the disease and impact on health –Patients deny their health conditions and MDs have to “scare” them into compliance

High Blood Pressure in Utah MDs in Utah qualitative data… –Physician challenges to treating hypertension: Time Patient denial Prescription costs Patients get conflicting messages-from media and pharmacists Non-compliance (meds better than lifestyle) Paperwork/spending time on those who can’t pay –Want patients to self-monitor blood pressure and take responsibility –Encourage patients to try lifestyle changes before medications are prescribed to lower blood pressure

High Blood Pressure In Utah Patients’ views… –Understand high blood pressure is serious –Those who take it seriously are better educated and informed –Those who show less concern say they have no symptoms and that medication can mediate the problem –Greatest fears center around possible loss of independence and/or early death –Drs fail to adequately educate patients about the specifics of the disease; patients want more information –Getting conflicting messages – advertising for fast food plus admonitions to eat right and exercise –Patients understand that untreated high blood pressure can lead to serious consequences-stroke, heart attack, kidney disease, early death, lower quality of life –Cost is an issue in treatment for those who are low income

High Blood Pressure In Utah Patients’ views… –Understand that high blood pressure can be controlled with medications, diet and exercise but find it difficult to follow diet and exercise recommendations – hard to find the will power –Family members can be supportive or push compliance too hard –Many believe it is their responsibility to take control –Want more information from MDs about high blood pressure, its ramifications and how to control it –Confident about self (or family) monitoring blood pressure –Like the idea of health insurance offering incentives to control high blood pressure –Most believe that self-management programs can work and put the responsibility on the shoulders of the patient – where it belongs –Very interested in a video designed for people with high blood pressure – seemed to mitigate lack of in-depth information from MDs –Prototype tracking booklet-received good, but not great scores

Blood Pressure Management Program The Utah Heart Disease and Stroke Prevention Program approached Utah’s health plans to work collaboratively to develop a comprehensive high blood pressure management program for physicians and members. SelectHealth and Molina Health Care agreed.

Blood Pressure Management Program Priorities Improve physician care provided to Utahns with high blood pressure Improve blood pressure self-management among Utahns with high blood pressure Reduce rates of high blood pressure not in control

Blood Pressure Management Program SelectHealth-UHDSPP Activities: –Blood pressure care guidelines developed and served as the basis of a statewide physician education program –Regional trainings for physicians on blood pressure management –Patient self-management education

“Blood Pressure (BP) Take Control” Patient Self-Management Education Prog Goals: –Improve understanding of high blood pressure –Improve self-management of high blood pressure –Monitor progress Components: –BP Basics –BP Tracker –DASH Diet –Walking Exercise Program Brochure –BP Cuff –Pedometer –Pill Box –BP Take control DVD

Blood Pressure Basics Understanding High Blood Pressure Managing High Blood Pressure Monitoring Your Progress

“BP Take Control” Lifestyle Materials Utahwalks.org Walking trails and maps Walking Tracker Pedometer DASH diet

“BP Take Control” DVD DVD produced by Utah HDSPP and Intermountain Healthcare Visual learning tool and patient motivator to take action in controlling blood pressure. 10 min

Interactive Voice Response High Blood Pressure Outreach Calls Outreach Goals –Engage more health plan members in conversations about their blood pressure –Identify health plan members with uncontrolled high blood pressure –Identify motivating factors to self-monitor –Inspire healthy behavior change in health plan members at a lower cost

Interactive Voice Response High Blood Pressure Outreach Calls Program Tactics –Computerized-voice response system –Interact with health plan members over the phone, at their convenience –Distribute self-management tools (i.e. blood pressure diary, walking program, pedometer, and blood pressure cuffs) to those who will use them –Provide tailored information and tips for achieving optimal blood pressure levels –Transfer members to customer service or a nurse, if needed

Interactive Voice Response High Blood Pressure Outreach Calls Interactive voice response telephone calls have been placed to members with hypertension, bi- annually.

“BP Take Control” Post Intervention Results Follow-up with members who received cuffs: –84% remembered the original outreach call –85% were using the cuff at least once a week –94% felt that the tools and information sent to them will help them improve their health –96% have seen their MDs about their condition as a result of the call –73% reported that their blood pressure improved since the initial outreach

“ BP Take Control ” Sample member comments post intervention “I really appreciated the program. I have changed because of the program and my BP is down.” “Being able to monitor my BP instead of going to the doctor has helped me quite a bit. I am not worried because I am feeling bad. I just check my BP and it puts my mind at ease.” "That was a nice package you sent me. I sure enjoy it. It is a constant reminder that I need to watch my BP.“

Blood Pressure Management Prog HEDIS Measures (2002, 2004, 2005)

High Blood Pressure in Utah in % of SelectHealth and 70.8% of Molina patients had blood pressure in control 19% of Utah adults reported high blood pressure (22.3% in 2001) (BRFSS) 27.1% Of Utah adults with high blood pressure are making lifestyle changes (BRFSS) 69% of Utah adults with high blood pressure are taking medication alone or making lifestyle changes in addition to taking medication (59.9% in 2001) (BRFSS)

Getting Health Plans to the Table Health Plan “Carrots”: –What gets measured gets managed, focus on chronic diseases associated with HEDIS measures. –Facilitation at the State level allows competing health plans to meet on neutral ground and agree to collaborate. –Pass through funds are valued by health plans to help mature or start chronic disease quality improvement programs. –NCQA Quality Plus Accreditation Standards (Physician and Hospital Quality)(2008) call for health plans to enter into collaborative associations with other plans to measure care provided by physicians. –Collaboration looks good in the public eye. State Program “Do’s”: –Try to work with the Health Plan Quality Improvement Coordinator. –Look at health plan data across plans and develop collaborative interventions based on the data. –Be open and willing to develop initiatives to meet the health plans’ needs.

Lessons Learned From Collaboration Health plans have access to members and families. Health plans have access to providers. Matching dollars and resources from health plans expands the impact of State programs. A consistent message from health plans to health care providers has more impact. Health plans have access to data for evaluation and monitoring – HEDIS. Health plans can be excellent partners with state programs.

Thank You!