1. Hypertension Best Practice Session 5 Health Literacy and Outreach Plan

2. Hypertension Best Practice Elements
BP measurement: include 2 BP readings if 1st 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 and state we will focus on the ones highlighted in red today.

3. Learning Objectives
Review process for obtaining a second blood pressure reading
Review process for timely follow-up
Develop a plan for outreach using HTN registry
Understand the importance of health literacy as it relates to communicating with patients
Read slide to share the objectives with the staff.

4. Data Review

5. Uncontrolled blood pressure by month
It is important for all members of the practice to know how well they are doing and see the 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. Include at least 2 months of baseline data.
In our example, in August 2015, the practice had approximately 50% of their patients with elevated BP and they were able to reduce this number by 17 percentage points over a 5 month time period.

6. Two BP readings when first elevated
Insert most recent data for your clinic. 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). It is important for all members of the practice to know how well they are doing and see the opportunities for improvement.
In our example here, the practice was recording a second BP when the first was elevate for about 17% of their patients. They improved over 5 months to 93%.
You will place your own practice data here.
For this graph, HIGHER is better

7. Two BP readings when first elevated
What is the current process?
How is it working?
Develop a goal for repeat blood pressure readings.
What action(s) will it take to achieve this goal?
If your practice does not have 80% of your patients with an elevated BP receiving a second BP measurement, then you will want to discuss your current process and develop/revise an action plan to improve these results. You will want to re-evaluate workflows.
Best practices from other clinics include utilizing BP alerts in your electronic health record system or some other flagging/reminder system to repeat the BP when the first BP measurement is elevated.
Also, we encourage holding staff accountable as part of their annual review to meet these measures, and addressing barriers to achieving this goal. Many health systems purchase BP machines which can automatically take more than one BP measurement to enhance efficiency of this process in primary care.

8. Timely follow-up data
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 two months of baseline data. It is important for all members of the practice to know how well they are doing and see the opportunities for improvement.
In our example, in November 2015, the practice was scheduling 25% of their patients who had an elevated blood pressure for a follow up visit. They continued to improve and in May of 2016 they were at 40%.
You will place your own practice data here.
For this graph HIGHER is better.

9. Timely follow-up process
What are some of the barriers to scheduling one-month follow-ups?
What are some ways to increase the number of patients who get a one-month follow-up visit scheduled?
If your practice does not have 70% of your patients with an elevated BP receiving a follow up appointment with the nurse/MA or the medical provider within 30 days, you will want to discuss barriers and devise an action plan to improve these results.
Some strategies our clinics used to improve their result were:
Scheduling the follow up appointment while the patient was in the triage room shortly after databasing the patient.
Implement protocols to have all patients with elevated BP scheduled for a follow up with the nurse or MA in 2 weeks and then 4 weeks with the provider unless the provider requests to see the patient sooner. A nurse/MA BP visit is no charge to the patient.
You are welcome to contact Better Health Partnership for more strategies.

10. Outreach

11. Outreach for uncontrolled BP patients
Discuss a process for conducting outreach to patients with elevated blood pressure.
What will the process look like?
Who will reach out to the patient?
How often will you reach out?
What method will you use to perform an outreach?
How will you measure the effectiveness of the outreach?
Discuss a process for conducting outreach to patients with an elevated blood pressure who have not been seen in the practice recently. Discuss the following:
What will this process look like? Will we contact all patients not seen in 6 months or 1 year?
Who will reach out to the patient? Will it be a nurse coordinator, the MA, or an administrator
How often will you reach out? Will it be monthly, quarterly, or every 6 months?
What method will you use to perform an outreach? Telephonically, patient portal, postal mail?
Develop a process to measure effectiveness of the outreach.

12. Outreach (continued)
Use hypertension registry to identify target population
Example target population and outreach frequency:
Adult patients seen by clinic in past two years with last BP ≥ 140/90 and no follow-up scheduled in next 35 days.
Frequency of outreach = every 6 months

13. Sample process for outreach
Here is a sample process flow for conducting outreach.
Attempt to contact patient 2-3 times or whatever is your practice policy

14. Example outreach message
Our records show that your last blood pressure was high (≥140/90mmHg). As you know, high blood pressure can lead to headaches, heart attack, kidney damage, and/or stroke.
Please call us at XXX-XXXX to schedule a NURSE blood pressure check in the next 30 days. Let’s work together to protect your health.
This is a sample of scripting your staff may use when calling patients .

15. Outreach next steps What process will work in your clinic?
Who will do the outreach?

16. Observation feedback Complete staff observation
using an observation checklist and provide feedback
Quality and competency checks are important for the HTN best practice. We encourage observation and feedback for assisting practices with workflow redesign. You may develop your own observation checklist or contact Better Health Partnership for further assistance.
Any global feedback you have from these forms can be added here to discuss with the practice or discussed separately.

17. Communication

18. Communication homework
Pair up
Discuss what went well when practicing and what was challenging
Share what you might do differently or continue doing
In session #4, we discussed empathy and communication strategies using the mnemonic IDEAL. Pair up with a partner (or discuss in small groups) the successes and challenges you faced while using the session # 4 communication strategy you identified at the last session you planned to practice. If they forgot to practice the strategy, ask them to share a patient communication story that went well or that was challenging, and what strategies they used that made it successful or that could have been used to make it more successful. After folks pair up for a few minutes, have one or two report back to the larger group about what they discussed.
The facilitator may want to review the strategies as listed below for reference and/or refer to the 3 slides from session # 4.
I – introduce yourself, attend to comfort
D – describe what’s next (including wait time)
E – elicit patient concerns
A – articulate/express empathy
L – leave in a positive way
AND the Strategies.
Focus on patient’s agenda
Draw out the story (okay, head nodding; listen to 3-5 sentences uninterrupted; opportunity to express patient concerns; ask probing questions; tell about yourself)
Demonstrate understanding – respond empathically; show caring; show familiarity with medical or social history)
Provide detailed explanation – what is happening and why; present options to patients
Complete the patient’s agenda – deliver what was promised or negotiate until later

19. Communication strategies from session No. 4
I – Introduce yourself, attend to comfort
D – Describe what’s next (including wait time)
E – Elicit patient concerns
A – Articulate/express empathy
L – Leave in a positive way
These are strategies we discussed in session # 4. Briefly show this and the next 2 slides.

20. Communication strategies from session No. 4
What do you think is the cause of this problem?
What course do you expect it to take?
How serious is it?
How does it affect your body and your mind?
What do you most fear about this condition?
What do you most fear about the treatment?
These are strategies we discussed in session # 4
(Kleinman et al., 2006)

21. Communication strategies from session No. 4
Focus on patient’s agenda.
Draw out the story. “OK”; head-nodding; listen to sentences uninterrupted; opportunity to express patient concerns; ask probing questions; tell about yourself.
Demonstrate understanding. Respond empathically; show caring; show familiarity with medical or social history.
Provide detailed explanation. What is happening and why; present options to patients.
Complete the patient’s agenda. Deliver what was promised or negotiate until later.
(Table 1 Tallman et al., 2007)
These are strategies we discussed in session # 4

22. video on health literacy.
Click here for a short
video on health literacy.
We will now watch a short video before we begin our discussion on health literacy.
After the video ask staff to provide feedback about what struck them the most in this video. You can also ask them what they do around health literacy in their practice. Allow time for discussion.

23. Communication: health literacy video
Video highlights:
Patients who speak well may not always read well
People sometimes feel ashamed if they are not able to read
It is important to explain diagnoses in simple language
It is important to assess medication adherence and give explicit medication instructions
Read Slide to highlight the key points from the video.
Health Literacy, A Manual for Clinicians, AMA foundation; Barry D. Weiss, MD states that 68% of people do not tell their spouses that they have difficulty reading and 52% do not tell their children.

24. Communication: Health Literacy
What strategies1 can be used to improve communication?
Teach-back method
Use of open ended questions, such as how people take meds
Explicit instructions on medications and purpose (e.g. Q12 hours on prescriptions instead of BID; for high blood pressure)
Limit to 3-5 key points
Use of pillboxes and color charts and pictures
Make all handouts applicable for low-literacy patients
Review the strategies for improving health literacy.
Teach Back: If the group has not already discussed teach back, ask them what this is. Then explain that teach back is saying to the patient something like “I discussed a lot of issues with you today. Can you repeat back to me the plan we made together to improve your health? That way I can make sure I explained everything correctly.” Then listen to the patient describe the plan and make any corrections as needed.
Open-ended questions asking how they are taking their medications
Explicit instructions - Explaining time of day for medications before breakfast and dinner and what the purpose is of the medication.
Limit changes to 3-5 key issues
Low literacy handouts - Make all handouts 5th grade reading level or less. You might also ask the patient if they would like the nurse to review the written materials with them briefly.
1Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN, Harden E, Tant E, Wallace I, Viswanathan M. Health Literacy. Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality. March 2011.

25. Skills Practice
Using drawings and/or simple words, describe the following to a patient:
Hypertension diagnosis
A low-salt diet
Allow staff an opportunity to practice health literacy skills. Have staff pair up and practice explaining one of the concepts on the screen to a low health literacy patient. Encourage staff to use simple language and/or draw pictures to convey the message. See supplemental folder to print the exercise to use as handouts for the practice staff/providers.
After the exercise have staff share their feedback.

26. Implicit bias
Refers to attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner
They are activated involuntarily and without an individual’s awareness or intentional control.
They cause us to have feelings and attitudes about other people based on characteristics such as race, ethnicity, age, and appearance.
READ Slide: Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.  These biases are activated involuntarily and without an individual’s awareness or intentional control.  Implicit biases are in our subconscious and they cause us to have feelings and attitudes about other people based on characteristics such as race, ethnicity, age, and appearance.  These biases develop over the course of a lifetime beginning at a very early age through exposure to direct and indirect messages.  In addition to early life experiences, the media and news programming are often-cited origins of implicit bias associations.
Source: Accessed

27. Implicit bias assignment
Take one of the Unconscious Biases Tests on the following website:
In the box titled PROJECT IMPLICIT SOCIAL ATTITUDES, click “GO!” to continue as a guest without logging in.
At bottom of next page, click “I wish to proceed.”
Take one or two of the tests [e.g. skin-toned IAT, implicit associations test]
Write a few sentences about your reaction to this test
Homework
Ask staff to go to Harvard University’s website and take 1 or 2 implicit biases tests prior to next session. The purpose of this assignment is to help staff become aware of their unconscious biases. Please express to staff that we all have unconscious biases. Only when we are aware of them can we take measures to “control or lessen their impact.” We will discuss this in more depth at the next session.
Provide staff/providers with the implicit bias homework questionnaire.

28. Next Steps Review Repeat BP Timely follow-up
Communication: implicit biases homework
Practice champion to review monthly data
Review what the next steps were for improving repeat BP and/or timely follow up. Also, remind them to complete the homework by the next meeting. Lastly, decide with the group who will be the practice champion (if not yet decided) to review monthly data with the practice and revise action plans. This is especially important as the sessions end.

29. 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.

30. 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)

31. Contact Info
For questions about the online toolkit or assistance with implementation, please contact our coaching team:

32. Thank you!