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Target: BP Check. Change. Control. Cholesterol

Tuesday, November 19, 2019   (0 Comments)
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Written by:Juliette Martinez, American Heart Association, Western States Consultant and
Millesa Park, Yakima Valley Farmworkers Clinic, Director of Healthcare Outcome Metrics



Yakima Valley Farm Workers Clinic (YVFWC) is an FQHC which has over 30 locations throughout Washington and Oregon. As part of its patient-centered approach to care, YVFWC Clinic works with community partners to improve the health of its patients by addressing needs like food, shelter, education, training, and more. One area that needed immediate intervention was improving hypertension rates in YVFWC’s patient population. With that goal in mind, Lesa Park, the clinic’s Director of Healthcare Outcome Metrics presented the Target BP program to leadership knowing that focus and change was a major goal of the organization. With this goal as the driving force, YVFWC joined the Target:BP and Check.Change.Control.Cholesterol initiatives, which resulted in 16 clinics receiving award recognition, 4 of those at the Gold level!


The efforts to bring Target:BP Check.Change.Control.Cholesterol into YVFWC first began with buy-in with leadership. Once the clinic’s executive team signed off, we began outreach to key department heads to start conversations about how to incorporate these initiatives’ recommendations into the clinic’s best practices. From prior program executions, using a team-based care approach was a crucial cornerstone of the efforts. Engagement included the Chief Operations Officer, Chief Medical Officer, the Nursing Supervisors, the department leads for the Pharmacy, Behavioral Health, Nutrition, Medical Assistants, and the clinic’s operational manager to discuss the current state of hypertension protocols systemwide. To help identify baseline metrics, the Health Outcomes Department completed the Quick Practice Assessment Tool and reviewed each clinic’s hypertension control rates using the 140/90 metric.



Each participating clinic began with taking blood pressure basics. Each clinic worked with their clinical manger to get the “M-Measuring Accurately” from the Target:BP’s M.A.P. framework in place. A critical piece of this included reviewing how to take blood pressure correctly, noting that some of the most common practitioner errors were: not using the correct cuff size, the patient’s feet not being supported on the floor, and the arm that the blood pressure was being taken on was not at heart level. After the team went through the training, the quality department conducted technique checks using the Technique Quick Check Tool, in which staff were observed multiple times on how they took blood pressure and given feedback on how they did. The staff were receptive to the information and really committed to taking blood pressure accurately, each time, every time. YVFWC also had access to PDFs of the In-Office Blood Pressure Graphic which the YVFWC staff appreciated as well.



After the “M” from the Target: BP’s M.A.P. framework was covered, YVFWC’s Executive leadership team then worked with YVFWC’s clinical leadership to get the “A-Act Rapidly” section moving right along. One of the gaps the YVFWC’s team had identified was that providers did not have the bandwidth to follow up with patients as frequently as they would like, post- appointment. To counteract this, the group took an innovative approach: incorporate a model using team-based care. Instead of relying solely on physician and nurse practitioners, the YVFWC team incorporated medical assistants, schedulers, dieticians, pharmacists, and interns to help drive patient follow-up. Additionally, a significant amount of the staff are bilingual, which helped patients convey information in whatever language was most comfortable for them. Patients were asked how they were doing as far as recommended lifestyle changes and how they were doing with pharmacology if prescribed. Based on the patient’s comments, the provider team was notified on the best way to assist the patient. For example, if a patient shared that they stopped taking their prescription, both the practitioner and pharmacist were informed so dosage could be reevaluated. The scheduler was also included so a follow-up appointment was booked for patient with their practitioner.


Another recommendation that Park gathered from the “A” in the M.A.P. framework was the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Calculator (provider version and patient version). The ASCVD Risk calculator can be used as a starting point for assessing ASCVD risk and to provide a baseline to initiate an open discussion with patients and guide decision-making regarding treatment options to prevent ASCVD. The recommendations included lifestyle changes, risk factor management, and pharmacologic treatment. YVFWC’s team could access either of the versions on their mobile devices and work with patients to understand their likelihood of developing vascular disease in the next 10 years. YVFWC also focused on the primary demographic for the ASCVD Risk and works to focus on this population on a daily basis.


After the “A-Acting Rapidly” was covered, the YVFWC’s team looked at the “P- Partnering with Patients” in the M.A.P. framework. Relying on the team based care model, the YVFWC’s staff encouraged patients to take an active role in their treatment plan. This included using motivational coaching to use positive reinforcement when a goal was achieved or to keep the patient on course if there was a setback. Staff followed up with patients on a regular basis via phone to see how they were doing which in turned helped build trust and foster open dialogues. The YVFWC team also promoted self-monitoring blood pressure to patients and shared resources such as information that could help them outside of the clinical setting, such as Life’s Simple 7 and Healthy for Good.


To celebrate YVFWC’s great start towards hypertension control rates, Lesa then submitted both systemwide and clinical level data in the Target:BP portal. In September 2019, YVFWC had 16 clinics recognized, with 4 being awarded Gold Level. Lesa is continuing to work with the YVFWC team to help monitor and provider tools related to hypertension initiatives and we look forward to getting an update from her in the near future.







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