Featured Articles: Quality Improvement

Blood Pressure under Control in Bremerton? Check!

Friday, April 10, 2015   (0 Comments)
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Jennifer L. Johnson-JoefieldBy Jennifer L. Johnson-Joefield, BSN, RN, Quality Director, Peninsula Community Health Services


In February 2015, Peninsula Community Health Services (PCHS) was honored with the 2014 Million Hearts Hypertension Control Champion award. Our rate of incidence for hypertension is 26.7% of our patients; this incidence rate is higher than the WA State average by 7% and higher than the national average by 3.1%. Yet we maintain a hypertension control rate of 76%, which is 12% higher than WA State and national rates of hypertension control. Having received this national recognition, we find our colleagues knocking on our door wondering, “How did PCHS do this?” The journey began in February 2010 and continues to evolve to this day!


First we were trying to manage chronic conditions

At first, this journey was less about hypertension specifically and more about establishing a path to manage chronic conditions. In 2010, the Pharmacy and Therapeutics Committee (P&T) worked together to establish a team approach to address follow-up care of all chronic conditions. This committee created the “Chronic Disease Follow-Up Guidelines.” These guidelines are what our pharmacists use to approve refills for routine medications for chronic conditions. For hypertension, the guidelines dictate monthly visits until a patient’s blood pressure is treated to goal (140/90). Once the patient reaches this goal, the guideline stipulates a three-month follow-up visit when the patient has other co-morbidities like diabetes, or a six-month follow-up visit for a patient without co-morbid conditions.


When patients need refills of their medications for hypertension, our pharmacists review each patient’s blood pressure and the date of their last office visit or upcoming office visit. If there is no upcoming appointment matching the guidelines, then the pharmacist tasks our Patient Service Center to contact the patient for a visit. Our pharmacists refill medications on behalf of our providers under a collaborative drug therapy agreement.


Naturally not every patient responds to the first request for a follow-up office visit. Next time that patient requests a refill, the pharmacist sees an appointment was requested and may approve a shorter- duration refill with another appointment request. Eventually, the patient will get his or her medication filled for only seven days, or the refill may be completely denied until the patient comes for an appointment. Luckily, not too many people require more than one or two contacts for an appointment.


Other transformations naturally evolved

After we launched this guideline, further processes and strategies came into play. Some strategies arose in direct response to the initial guideline, while others responded to the healthcare scene at the time.


One challenging transformation was agreeing as a practice to minimize the use of the classic nurse visit for blood pressure checks. Patients coming for a short visit with the Medical Assistant (MA) to have their blood pressure checked produced a higher number of patients who were lost to follow-up when compared to patients seen for hypertension in an office visit with their Primary Care Provider (PCP).


During the blood pressure check visit, the MA measured and recorded the blood pressure and tasked this reading to the patient’s PCP to act upon. The problem was that the provider did not get to see the patient during this interaction, when their blood pressure was not at goal. Providers missed out on gathering any information about why the patient’s blood pressure remained high. Is the patient taking the prescribed medications, experiencing side effects, under extra stress, gaining weight, eating poorly?


This gap in information meant patients who came just for a blood pressure check had to come back again for a complete office visit with the provider to delve into the full issue and to make a treatment plan. Patients who had to return so soon for the same problem were not satisfied with their care and often stayed away from the clinic for a longer period of time than patients who had their hypertension follow-up visit with their PCP to begin with. Given the clear need for hypertension to be managed by the patient’s PCP, the provider team elected to greatly reduce the utilization of this blood pressure check nurse visit. As a team, providers agreed: Patients needing blood pressure checks should see their PCP for optimal care and management of their hypertension.


The provider team was critical to success

While redirecting the blood pressure check nurse visit sounds simple, it was not a popular change for some providers, nor for the patients experiencing stable hypertension at that time. However, this example precisely highlights one fundamental strength of our Medical Provider Team at PCHS. The team is made up of a combination of 23 providers who include Family Practice Doctors, Internists, Nurse Practitioners, and Physicians Assistants.


Getting this many practitioners with this wide a variety of disciplines to agree to the same treatment guideline and follow-up schedule was inspiring. It is at the monthly provider meeting where the magic happens. Every month a provider or pharmacist presents clinical information on a specific topic about medications or best practice treatment guidelines for our most common chronic conditions. Content delivered by a peer produces a unique collaborative dynamic. The source of information is always a trusted national source; after each presentation the providers engage in discussion about how to use this information to transform their practices as a group.


Over time providers see how impactful for both the individual patient and the population it is to be united in their treatment and disease management. Practicing as a team and agreeing to the same expectations for follow up and management of chronic conditions among professional clinical staff really works for patients. Patients get consistent messaging and experiences that shift patient behavior, but the effect also positively impacts the culture of the clinic.


Innovative staffing and good data play important roles

Another feature of the team-based care not to be overlooked is the creation of a specific visit type called “Hypertension Office Visit.” This visit type generates a report for recall and follow-up. We have MAs we call “Healthcare Specialists” (HCS) who are not assigned to a provider, like other MAs, but are assigned to a clinic instead. HCS staff provides additional care support and patient management most similar to case management. HCS staff ensure we follow up with our hospital admits, contact diabetic patients regarding overdue care, and perform enhanced office visit patient education like tobacco cessation or inhaler teaching. HCS staff also receive training on the DASH diet so they can teach the DASH diet principles to hypertensive patients as requested by providers. For hypertension, the HCS team is responsible for the Hypertension Office Visit report and helps make sure no patients are lost in the system, failing to fill medications, come to appointments, etc.


About four years ago, PCHS saw the need to create a formal Quality Department tasked with studying our data and working to improve patient care. The Uniform Data System (UDS) data required by all Federally Qualified Healthcare Centers (FQHCs) was an obvious place to begin. This data set includes a measurement about hypertension control. There we found data that gave all the team members feedback about the patient population and how it was improving. At PCHS, data is widely and transparently shared quarterly with clinic staff and providers. Having this information serves as a tremendous informer and motivator for clinical staff.


Each part of the care team plays a role in treating hypertension at PCHS:

  • Provider / PCP – Diagnose and treat HTN to goal
  • Pharmacist – Refill HTN medications, checks on blood pressure measurements and HTN appointment follow-up according to the guideline
  • HCS – Teach the DASH diet and work the Hypertension Office Visit report
  • Patient Service Center – Contact patients and schedule the “Hypertension Office Visit” appointments
  • Quality – Report quarterly to all staff the hypertension control rate at PCHS


A positive response to inevitable change

It boils down to PCHS having been subjects of the perfect storm of healthcare change. The tremendous changes in healthcare over the past few years to address quality, to provide patient-centered medical homes, to manage chronic conditions, and to approach care as a team is what PCHS responded to. The storm of change gave rise to this beautiful outcome of hypertension control.


PCHS has not arrived at its destination; we continue to evolve. Recently, we joined the local health district in a community-wide grant to address hypertension in Kitsap County. As partners in this grant, we are initiating Pharmacist Hypertension Visits. Our clinical pharmacists will see hypertensive patients for a face-to-face visit to check their blood pressure, and, unlike the old blood pressure check nurse visit, the pharmacists have the ability to adjust the patient’s medications. This step further enhances the care team relationship between the providers and pharmacists as they work together to get patients’ blood pressure treated to goal.


Additionally, as national attention is highlighting the problem of undiagnosed hypertension, PCHS created a report which identifies patients in our health record with blood pressures over 140/90 without any hypertension diagnosis. Right now, this report is in the hands of the pharmacy team. We are excited to see what process or system flows from this proactive report to make sure we not only treat the diagnosed, but that everyone who ought to be diagnosed and treated is identified and appropriately managed.


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