1. Shifting our systems toward value: Primary Care Quality and Equity
Thursday, June 22, :15 – 2:45pm
Ellen H. Chen, MD
Primary Care Director of Population Health and Quality
San Francisco Health Network
San Francisco Department of Public Health
Dia Yang
Performance Improvement Coordinator
San Francisco Health Network
San Francisco Department of Public Health

2. 70,000 unduplicated patients 27% uninsured 73% public insured 4
SFHN is the service delivery arm of the Department of Public Health, which is part of City and County of SF.
Zuckerberg San Francisco General Hospital (4 hospital based primary care clinics, XX Specialty Care Clinics, ED and Inpatient services)
Laguna Honda Hospital and Rehabilitation Center
10 community based health centers
Over 20 additional behavioral health sites
70,000 unduplicated patients
27% uninsured
73% public insured
48% males & 52% females
83% adults & 27% pediatrics

3. SFHN and Medicaid Waiver Progression
Integrated care for the enrolled population for whom we are clinically and financially responsible
High quality care for the individuals who present for care
Medical home, population health approach for all active patients
Integrated delivery system for patients who present for care
accountable care organization
medical
home
primary care health center
medical
neighborhood
PC based pop health approach to QI
quality and cost data linked to improvement infrastructure
quality management
shared responsibility for patient care
HSF
DSRIP
PRIME/GPP/WPC
slide courtesy of Hali Hammer

4. Vision for SFHN Primary Care
Leadership messaging

5. Prevalence Treatment Efficacy Why focus on HTN?
About 1/3 of US adults, 75 million, have high blood pressure
About 1/4 of SFHN PC patients, 18,000, have high blood pressure
54% of these adults have their BP under control
In 2014, 61% of SFHN PC adults with HTN had their BP under control
Treatment Efficacy
Patient Conditions:
Stage 1-3 hypertension
One or more CV risk factors
Treatment:
Reduce SBP by 12 mm Hg
Prevent 1 death in 11 patients over 10 years
Ogden LG, et al, Hypertension, 2000;35:
One condition of focus, most common diagnosis
Focus to build infrastructure for population health management- use of registries and team-based care and self management support
High Blood Pressure. CDC.

6. Why focus on equity?
In 2015, 53% of Black African American adults with HTN had controlled BP, compared to 61% of all SFHN PC adults with HTN.
PRIME includes metrics about REAL data and closing disparity gap
Quality Improvement interventions can affect populations in different ways

7. TRUE NORTH DRIVER METRIC MESSAGING
Leadership and data messaging
10/2016

8. Data to drive improvement
Clinic and provider level dashboards
Data sharing

9. Using Qi & Lean methodology
Root cause analysis: Sub-optimal BP Control
Prioritize ideas & interventions
Clinics share best practices
Medication Algorithm
Standard BP Measurement
Risk stratification guidelines & Registry Lists
RN & PharmD Chronic Care Visits
Home BP monitoring
Fishbone
Ideas
Priority Grid
Interventions

10. Using A team based care model to manage hypertension
Health coaching
Medication algorithm
Standardized blood pressure measurement and documentation
Smoking cessation counseling
Equity workgroup
Patient navigators
Primary Care Provider
Ancillary Services
Pharmacist
Nurse
Medical Assistant
Front Office Admin
Behavioral Health
RN chronic care visits (RNCCV – HTN)

11. Key Tasks
Status
True North Messaging
Create standard messaging tool
Done
Test & revise messaging tool
Use of data for to drive improvement
Active Patient Panel Clean up Lists
Repeat BP Report
HTN i2i registry lists, then Tableau Dashboard
Risk Stratification Worklists
Test
Clinical Guidelines
Provider CME – Medication Algorithm
Clinic Site Visits
Referral Guidelines
FAQ
Standard Work (SW)
*RN CCV = RN Chronic Care Visit
Standard BP Measurement
Develop & test RN CCV SW
Spread RN CCV SW
Start
Lifestyle changes & Home BP monitoring
Equity Workgroup
On-going
Develop Home BP Toolkit & Patient Education Materials
Spread Home BP Toolkit & Patient Education Materials

12. Improvement in proper bp measurement
Standard BP measurement training materials and training
Observation checklist
Performance report for daily coaching

13. Guidelines to support team-based care
RN/ Pharmacist/ PCP referral guideline
Medication algorithm

14. Rn Chronic Care Visit – project design
Optimize
Aug-Dec
2017
Expand RN chronic care visits to other chronic conditions
Spread & Sustain
Jan-July
Tiered roll-out to additional 8 PC clinics
Validate & Adapt (PDSA)
May-Dec
2016
Pilot standard work at 4 Primary Care sites
Design & Test
Jan-Apr
Rapid Improvement Event

15. RN CCV – Pilot results Metric Pre-RN Visit Post-RN Visit
% of patients seen by RN with controlled BP
23% (n=186)
67% (n=186)
(10/ /2016)
Average # of visits/patient seen by RN until BP controlled
N/A – RN chronic care visits had not started or were not occurring consistently
2.1 visits
% of RN visits requiring PCP consultation
25% (n=222)
% of RN visits requiring RX sent
30% (n=222)
Median Cycle time for RN Visits
32 min

16. Designing our Equity interventions
Stage 1: Materials for engagement
BAA patient handout
Health coaching toolkit for Home BP monitoring
Pilot outreach events
Stage 2: Modalities for engagement
Outreach
RN chronic care visits and training
Food Pharmacy pilots
Clinic and community outreach events

17. Stage 1: Materials for engagement
BAA patient handouts
Health coaching toolkit for Home BP monitoring
Focus on self management support

18. Stage 1: Pilot clinic outreach events

19. Stage 2: Modalities to engage patients
Paired with
Food Pharmacy pilots and outreach events
RN visits and Home BP cuff coaching

20. Hypertension Blood Pressure Control rate

21. Next Steps Lessons Learned Challenges
Dissemination of tools & resources to clinics
Spread tested models
Expansion of learnings to other chronic conditions
Lessons Learned
Leverage incentive programs for population health management infrastructure
Develop consistent messaging from leadership to front line staff (with data)
Involve the whole team in hypertension care
Address Equity with a Quality Improvement lens
Training teams together
Dynamic and timely data reporting
Variation among clinics
Challenges

22. ACKNOWLEDGEMENTS
Funding from Kaiser Permanente’s Preventing Heart Attacks and Strokes Everyday initiative
Blue Shield of California Foundation for diabetes improvement
Primary Care Nurse Managers, RN leads and pharmacists
Hypertension Equity workgroup staff and patient advisors
Community Health & Equity Promotion Section
UCSF Center for Vulnerable Populations

23. Contact information:
Ellen H. Chen
Dia Yang