1. “Caring for our community’s health since 1973” Presented By Debra Rosen, RN, MPH Director, Quality & Health Education CCALAC Symposium All Heart Hypertension Program April 1, 2016

2. “Caring for our community’s health since 1973”  FQHC Los Angeles County 14 sites 65,910 users/patients  291,152 visits in 2014  23% state they are best served in a language other than English  98% below 200% of FPL  81% below 100% of FPL  43.8% adults uninsured  6.8% of children uninsured 2

3. “Caring for our community’s health since 1973” 3

4. Why Santa Clarita?  All Heart Hypertension Project Objective at NEVHC ◦ To increase the percentage of patients at the Santa Clarita Health Center with controlled hypertension based on the JCN8 Guidelines.  Based on the JCN8 guidelines, 70.7% of patients had a diagnoses of controlled hypertension in December 2014 ◦ However, 57% of patients had a diagnoses of hypertension at our Santa Clarita Health Center during the same time period.

5. “Caring for our community’s health since 1973”  In-service presentations of the JNC8 Hypertension Guidelines to providers  Brought the data to the providers  Conducted research into race/ethnicity, BMI and Smoking rates  Asked the providers and care team what they thought  Asked them how we might improve  Presented ideas and options  Engaged providers and care team 5

6. “Caring for our community’s health since 1973”  Hypertension control rates at our Santa Clarita Health Center improved from 57% to 74.5% from December 2014 to January 2016. 6

7. “Caring for our community’s health since 1973” 7 HTN Class

8. “Caring for our community’s health since 1973” 8  Intervention  Produced site comparison data, presented to SC  Presented JCN8 Guidelines to providers  Implemented monthly hypertension class/BP lending program  Began Clinical Pharmacy Services  Comprehensive review of medical records  Recommendations for changes  Developed template and face to face MTM

9. “Caring for our community’s health since 1973” 9

10.  Santa Clarita Health Center Provider’s Role: ◦ Review specific lists of patients whose hypertension was not controlled ◦ Utilize newly developed protocols to review the recommended changes and to implement the changes him/herself ◦ Refer patients to the Clinical Pharmacist for one to one intervention 10

11. “Caring for our community’s health since 1973”  The Clinical Pharmacist’s Role: ◦ Completed a comprehensive review of the medical records for patients with uncontrolled hypertension. ◦ Recommended changes in medication for patients ◦ Created a protocol that allowed her to see patients with Hypertension one-on-one for medication management ◦ Established a schedule/template at the Santa Clarita Health Center to provide intensive education and medication therapy management. 11

12. “Caring for our community’s health since 1973”  Inclusion Criteria: ◦ Adult patients (18yo and older) diagnosed with HTN and with least 2 or more blood pressure readings not at goal during the last year  Exclusion Criteria: ◦ Evidence of end-stage renal disease (ESRD), kidney transplant, dialysis, diagnosis of pregnancy, secondary causes of HTN (e.g. thyroid problems, Cushing syndrome, aldosteronism)  Exit Criteria: ◦ Patients who meet 2 consecutive blood pressure readings below target at least 1 month apart and are adherent to medication regimen 12

13. “Caring for our community’s health since 1973”  The patient education session included: ◦ Explained Hypertension and the consequences of uncontrolled Hypertension ◦ Emphasized optimal control to prevent complications and define the patient’s blood pressure goal ◦ Discussed the importance of medication adherence/compliance. ◦ Identified strategies to improve medication adherence ◦ Counseled patients on lifestyle modifications to enhance blood pressure control 13

14. “Caring for our community’s health since 1973” Challenges Blood Pressure Texting Program Patients had limited interest Subsequently, Care Message’s Goal Setting Program was introduced and implemented at NEVHC Establishing a Clinical Pharmacist as a provider The provider needed to learn proper documentation in the medical record Space issues Limited support staff to help contact patients to make appointments and follow-up for broken appointments. Providers responding to the recommendations by the Clinical Pharmacist Initially there were limited responses 3 choices were provided for providers to respond a)Chose to not make recommended changes b)Provider will make recommended changes c)Provider will refer patient to the Clinical Pharmacist

15. “Caring for our community’s health since 1973”  CareMessage™ health coaching program: Highly engaging text messaging campaigns to improve health literacy and disease self-management for chronic disease.  NEVHC sent out an initial “Welcome” text through i2iTracks informing them of the program. (Patients can opt out by using “STOP”).  Patients are then enrolled in a 12-Week Goal Setting Program. Patients choose a Nutrition or a Physical Activity goal.

16. “Caring for our community’s health since 1973”  NEVHC has sent 4,480 “Welcome” text messages since October 2015 to patients with a diagnosis of “overweight/obesity”. ◦ Staggered Implementation  Total of 4,347 enrolled (only 133 opted out).  To date, 2,528 have completed the Goal Setting Program ◦ 81% Engagement (response rate).  1,320 are currently In progress  181 participants started the program, but did not complete it.  318 opted out at some point during the 12-week program

17. “Caring for our community’s health since 1973”  Initial feedback has been extremely positive.  Patients really like the program – the reminders and motivation keep them on track.  Some patients think we are providing personal responses to their text messages  Other patients have responded back via text; ◦ “Thank you for caring about me.” ◦ “Thank you for worrying about us” ◦ “I love it” 17

18. “Caring for our community’s health since 1973”  While hypertension control rates increased at the Santa Clarita Health Center, overall HTN control rates decreased slightly. NEVHC is spreading interventions including: ◦ Provide HTN rates by provider for each of the health centers ◦ Generate lists of patients who are not under control by providers ◦ Continue hypertension classes and the BP lending program at various health centers ◦ The Clinical Pharmacist will continue to participate in monthly classes to provide additional education on medication therapy ◦ Developed protocols for pharmacists to change/add medications  Approved by medical administration  Signed by providers 18

19. “Caring for our community’s health since 1973”  Finding different methods to engage providers and care team in the change process ◦ Assessing current provider and care team engagement ◦ Collaboration of ideas and options ◦ Site specific interventions  Successful interventions were based on the level of provider and care team engagement ◦ Sharing non-judgmental data was key ◦ Share best practices, but acknowledge each site is different in population, staffing and patient engagement 19

20. “Caring for our community’s health since 1973” Debra Rosen, RN, MPH Director, Quality and Health Education Northeast Valley Health Corporation (818) 270-9700 ext. 41517 debrarosen@nevhc.org Fabiola Escalante, PharmD. Ambulatory Care Pharmacist Northeast Valley Health Corporation (818) 365-8086 ext. 52250 fescalante@nevhc.org 20