1. hypertension Case Study 2017 Nicolas E
hypertension Case Study Nicolas E. Davies Community Health Award of Excellence Unity Health Care, Inc. Washington, DC

2. Overview
About Unity Health Care
Hypertension Case Study

3. HIMSS Davies Application Team
Catherine Anderton, Associate Director for Quality Improvement and Research
Angela Diop, VP of Information Systems
Marcia Hinkle, Assistant Director Social Services: Behavioral Health
Cherie Jones, Information Systems Manager
Andrew Robie, Chief Medical Information Officer

4. About Unity Health Care

5. Unity Health Care Federally Qualified Health Center
District of Columbia
Over 106,000 patients and 500,000 visits each year
Promoting healthier communities through compassion and comprehensive health and human services,
regardless of ability to pay. 5

6. Unity Sites 10 Community Health Centers
Medical Sites in Homeless Shelters 2
School-Based Health Centers 1
Mobile Van
Health Services in DC Jail
Homeless Outreach
Administrative offices

7. Services Primary care and specialty care Dental care
Behavioral health care
Care to people experiencing homelessness, HIV, returning citizens, Title X
Patient-Centered Medical Home NCQA level 3
Hypertension
Diabetes
Hyperlipidemia
Obesity
Asthma
Tobacco Use
Mental Illness
Substance Abuse & Addiction
HIV/AIDS
Viral Hepatitis

8. Unity’s Health Information Technology
Customized integrated PM, EMR and Dental applications
Implemented March – December 2009 in a phased approach (6 phases)
Over 260 licensed providers
Over 900 staff
6 applications analysts 8

9. Change Management
Robust system of change management helps to develop and adopt well thought-out changes in an organized manner.
From Unity’s change management Guidelines for Electronic Health Records ~2016

10. Unity Teams Responsible for EHR Governance
Team Name
Team Lead
Other Participants
Responsibility
Stakeholders
EHR Analyst
EHR Analysts, Deputy CMO, CNO, VPs of Clinical Services and IS
Approve major changes to EHR and workflows. Approve and assign resources needed for change.
Implementation team
VP of IS
Deputy CMO, CNO, VPs of Clinical Services, IS and Grants, EHR, PM, IT and Data Analysts, Lab Mgr., IT, CTO, Dir. Social Services, Revenue Mgr., Help Desk Asst.
Track issues and changes to resolution. Assign issues to other teams for solution. Implement and communicate changes.
EHR tech team
EHR, PM, IT and Data Analysts, VP IS, CTO, Revenue Mgr.
Responsible for managing ongoing maintenance, upgrades and implementations.
Joint training team
PM and EHR Trainers, Discipline Subject Matter Experts
Develop EHR and PM training.
Support team
EHR Analyst and Help Desk Asst.
EHR, PM, IT and Data Analysts
Respond to requests for support. Interface with the EHR vendor to track and resolve vendor related issues.
Reports team
Data Manager
Data and EHR Analysts, Deputy CMO, CNO, VPs of IS and Clinical Services, QI Mgr.
Develop EHR reports.
Configuration team
EHR Analysts
EHR Analysts, Deputy CMO, CN0, Dir. Social Services, 10 Medical Directors
Manage major configuration and content changes to the EHR

11. Our Approach
Develop Workflows
Modify EHR
Train Staff
Change

12. Workflow Development Groups Developing the Workflows QI Department
QI Working Groups
Configuration Team
In collaboration with Health Information Technology Team (HIT) and Reports team.

13. Disseminating Change Change is developed
Working Groups develop training
Multi-disciplinary team-based training is conducted
Training is reinforced
CHANGE!
Disseminating Change

14. Hypertension Case Study

15. Local Problem

16. Chronic Hypertension Major Cause of Heart Disease
Heart Disease remains the No. 1 cause of death in the US.
~American Heart Association
*National Vital Statistics Report – June 30, 2016

17. Disparity in Hypertension in the District*
African American residents of Washington, DC are two times as likely to have high blood pressure as white residents, and twice as likely to die from stroke.
*District of Columbia Community Health Needs Assessment, Feb , BRFSS data on the prevalence of hypertension in the District: “Have you ever been told by a doctor, nurse or other health professional that you have high blood pressure?”

18. Unity’s Patients and Hypertension
Hypertension is the number one diagnosis affecting Unity Health Care patients
We care for more than 20,000 hypertensive patients each year
More than 1 in 5 of Unity’s adult patients have hypertension

19. Hypertension Goal
Increase the percentage of patients with hypertension whose blood pressure is controlled
Baseline December 2013: 54% of patients diagnosed with hypertension were considered controlled with a blood pressure reading less than 140/90

20. Alignment of priorities and external incentives
Balanced Score Card 2014
Hypertension Control
Unity Balanced Scorecard Goal:
SMART Aim: We will increase the % of patients age 18 to 85 years with hypertension whose blood pressure at last visit was < 140/90 from 54% to 64% by December 31, 2015.

21. Hypertension Workflow
MA measures BP using proper technique, including repeat measurement if elevated
Provider assesses patient, including barriers to achieving BP goals; formulates treatment plan, including follow-up within 30 days if BP elevated
Registration clerk schedules follow-up visits
Nurse re-assesses BP and patient understanding of, agreement with treatment plan at BP-focused nurse visit

22. How Health IT Was Used

23. EHR Modifications/Set-up
Alerts
Reset BP alert to turn red at 140/90
Alerts for medication-allergy and medication-medication interaction were enabled
The EHR automates formulary checks helping providers reduce barriers to medication adherence
140/90

24. EHR Modifications/Set-up
Clinical Decision Support for Providers
Hypertension progress note based on JNC-8
Structured preventive medicine documentation populates visit summary with patient education and goals

25. EMR Modification/Set-up
Created a new visit type, “Nurse BP Follow-Up Visit”
EMR template supports clinically comprehensive visit, nurse decision points on referral back to provider, patient education, and correct documentation, including coding
Preventive medicine section in nurse visit documentation reiterates goal BP

26. Data Transparency Reports were generated from the EHR
Progress was reported to health center leadership at QI meetings
Increases in repeat BPs from 0-60 percentage points

27. Staff Training
President Obama and President Mills of Ghana. Note President Mills is in perfect position for BP check!
Staff trained in teams
Training included review of HTN, how to take blood pressure, how to document and how to follow-up
Training was recorded, placed on learning management system
Compliance with training was tracked
President Obama and President Mills of Ghana. Note President Mills is in perfect position for BP check!

28. Engaged Staff Healthy Competition
Created the Heart of Gold award (HOG)
Columbia Road Health Services, first winner of the Heart of Gold Award

29. Engaged Patients Follow-up patients within 30 days when BP not at goal
Easy for them to make a Nurse Visit appointment for repeat BP check
Automated reminder calls
Shared goals with patients
Preventive medicine section provided in the visit summary
QI posters at the sites

30. Value Derived

31. Phased Roll-out Preliminary Phase
Evaluation of 2 health centers in areas of DC with high HTN prevalence. EMR data dispelled commonly held notion that walk-in patients constituted the majority of those with uncontrolled HTN
Phase 1
Provider configuration for HTN
“Red, Rest, Repeat” staff training on proper BP measurement technique
Phase 2
Nurse BP visit template and workflow

32. Results
Blood pressure control improved by 9.3 percentage points

33. ROI
Hard ROI
$415,000 due to increased revenue from hypertension nurse visits
Soft ROI
Increased access because of nurse visits
Increased provider satisfaction
Expansion of the role of medical assistants and nurses
Growth/expansion in team based care resulting in more efficiency

34. Lessons Learned
Aligning with corporate goals makes it easier to get the resources needed to be successful
We can significantly impact HTN control (improving 5-10%) by using multidisciplinary teams throughout all phases of the project
Don’t just plan training; also plan how to reinforce it
Doing the project in phases provides opportunities for layered learning
Think broadly about which team members will be affected by the changes. Often change impacts people on the team that seem to have nothing to do with the project

35. Thank you www.unityhealthcare.org @UnityHealthCare