1. Million Hearts: Hiding in Plain Sight Initiative

2. Million Hearts Overview Consider... How many patients in your organization are clinically hypertensive but undiagnosed? How many preventable heart attacks and strokes will happen as a result?

3. Why should we care? 3

4. Why Should We Care? 35.8 million U.S. adults with uncontrolled HTN 1 14.1 million (39%) are not aware of their HTN 1 U.S. prevalence of HTN is 29% - how does your health center compare? 1 Every 44 seconds, someone in the U.S. has a heart attack 2 Every 4 minutes, someone dies of a stroke 2 1.National Health and Nutrition Examination Survey, 2003-2010, CDC 2.Million Hearts

5. Hypertension Costs Why Should We Care? - $31,106 for patients with ischemic heart disease (IHD) - $17,298 for those with cardiovascular disease (CVD) - $18,693 for those without IHD or CVD 1 Annual per person expenses of treating HTN with outpatient visits and medication: $784 2 Consider costs from a value-based model perspective – health system and shared savings, performance incentives 1.Wang G, Zhang Z, Ayala C. Hospitalization costs associated with hypertension as a secondary diagnosis among insured patients aged 18-64 years. Am J Hypertens 2010;23:275-281. 2.Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality, 2012 It’s a huge health care cost Estimated average costs for HTN- related hospitalization:

6. WMillion Hearts Overview Why Should We Care? Life expectancy 5 years longer in those with normal blood pressure than those with high blood pressure 1 Lowering blood pressure by 5 mmHg diastolic reduces the risk of stroke by 34% and ischemic heart disease by 21² Antihypertensive therapy associated with: 1.Franco OH, Peeters A, Bonneux L, de Laet C. Blood pressure in adulthood and life expectancy with cardiovascular disease in men and women: Life course analysis. Hypertension. 2005;46:280. 2.Law M, Wald N, Morris J. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health Technol Assess. 2003;7(31):1-94 3.Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52. Controlling HTN works - 35% to 40% reduction in stroke - 20% to 25% reduction in heart attack - Over 50% decrease in heart failure³

7. Who participated in the pilot? 7

8. Million Hearts Organizational Chart 5 HCCNs 6 States 10 – 15 Health Centers At least 20,000 adult patients, ages 18- 85 per network (100,000+ patients) Project Participants

9. What did we accomplish? 9

10. Million Hearts Overview Purpose Improve awareness and control of HTN, and ultimately, health outcomes Get the true hypertension population denominator right Improve detection and diagnosis of hypertensive patients “hiding in plain sight” at health centers

11. Million Hearts Overview Aims 3. Develop and spread tested change package to additional health center sites 2. Successfully embed algorithm into clinical and information workflows, leveraging HIT, QI, and expanded care team 1. Develop/test undiagnosed HTN algorithm in health centers

12. How did we accomplish It? 12

13. Knowledge Gathering (Planning) 8 weeks Ramp Up (Development) 8 weeks Accelerated Action Period (Implementation) 16 weeks Evaluation and Harvest 8 weeks Million Hearts Structure Project Phases

14. What is needed from participants? 14

15. What’s Needed... Empower teams to create and sustain system changes Provide adequate time to meet internally and participate in larger learning community Allocate resources needed (e.g., staff, tools, software, equipment, meeting space needed) Establish policies that support the adherence to developed workflow/protocol. 15 … From Leaders Alignment/integration with strategic, business, and QI plan for the network/health center

16. What’s Needed... Committed project team – at least one clinical champion, one QI leader, one HIT leader and/or EHR specialist, and appropriate care team end users at each geographic site Engage in collaborative learning opportunities 16 … From Teams Conduct internal project meetings, as needed, to monitor progress Review “current state” HTN diagnosis workflow Participate in feedback and coaching led by HCCN staff

17. What’s Needed... Complete organizational system changes and EHR configuration needed to support implementation of an undiagnosed HTN algorithm Review “improved state”: document new workflow, findings, and lessons learned for change package 17 … From Teams

19. - IvyExec “…many times we forget that great accomplishments start small and build momentum. Take Apple…at first just a small idea that was executed extremely well and consistently.”- IvyExec small scale “ While all changes do not lead to improvement, all improvement requires change.…After generating ideas, run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to see if they result in improvement. If they do, expand the tests and gradually incorporate larger and larger samples until you are confident that the changes should be adopted more widely.” Institute for Healthcare Improvement - Institute for Healthcare Improvement small scale “ While all changes do not lead to improvement, all improvement requires change.…After generating ideas, run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to see if they result in improvement. If they do, expand the tests and gradually incorporate larger and larger samples until you are confident that the changes should be adopted more widely.” Institute for Healthcare Improvement - Institute for Healthcare Improvement “No testing sample is too small. Sometimes it is best to test a change on one…before implementing the change on a broad scale. Each successive test provides new learning…ensuring a high likelihood of success once the change is fully implemented.” - Institute for Healthcare Improvement “No testing sample is too small. Sometimes it is best to test a change on one…before implementing the change on a broad scale. Each successive test provides new learning…ensuring a high likelihood of success once the change is fully implemented.” - Institute for Healthcare Improvement Small Think Big, But Start Small

20. Hypertension Protocol Status Change Concept #1 Change ConceptResourcesOperationalization Leveraging Additional Staff, A team-based approach 1.Recall Reports 2.Front Office Script 3.CDS Worksheet 4.Workflow Map -Train front office to participate in the project, use script for recalling patients -Develop workflow map, color coded -Recall patients as a team from the recall reports

21. Hypertension Protocol Status Change Concepts in Action

23. Hypertension Protocol Status Change Concepts in Action

24. Hypertension Protocol Status Change Concept #2 Change Concept ResourcesOperationalization Blood Pressure Checks/Hybrid Visits 1.Recall Reports 2.Morning Huddle 3.Workflow Guide team -Decide, as a care team, when BP visits are convenient for conversion -Use recall report to schedule BP visits -Use huddle as an alert for scheduled patients who meet criteria.

25. 25 Change Concepts in Action

26. Hypertension Protocol Status Change Concepts in Action

27. Hypertension Protocol Status Change Concepts in Action

28. Hypertension Protocol Status Change Concept #3 Change Concept ResourcesOperationalization Data sharing 1.Data monitoring and feedback tool 2.MillionHearts toolkit (i2i) -Use toolkit to monitor progress and successes at leadership/management level -Share data monitoring tool (fewer measures) with care team(s) to enlist ideas to create bigger/better impact and to create competition among care team participants

29. Hypertension Protocol Status Change Concepts in Action: Individual Care Team Data

30. Change Concepts in Action: Blinded Team Data

31. Critical Success Factor(s): Think Big, But Start Small. This focus… Promotes a focus on people Allows the sharing of data without being punitive Enables the project team to keep the momentum for change going throughout the period Facilitates engagement and group problem solving Keys to Success

32. Resources Due to the fact that we started small, there were a few less resources required. However, in order to ensure engagement and that momentum is kept, the project team has to devote time and resources to the project; active involvement from the following positions was key: QI Coaches, Director of QI, Director of Operations, Project Manager, Center Manager, Center Supervisor(s), Provider, Care team (front and back office), Medical Leadership, IS department, Project team members, etc. Resources

33. Million Hearts: Year Two control Increase blood pressure control in participating health centers by 10% from baseline (January 31, 2015) by June 30, 2016, with a longer-term goal of achieving 75% control, among adults ages 18 to 85 10% = 3,700 lives 75% control = 13,780 What’s Next?

34. Join The Effort 34