Division of General Internal Medicine Hypertension Impact Project

September 21, 2017

Integrated Network Summit

Presented by: Mark Earnest, MD, PhDLauren Drake, Wagner Schorr-Ratzlaff MD, Huong Lam MD, Laurence Williams MD, Mary McCord MD, Hillary Chrastil

MHA, Mary Kozloski, Carmen L. Lewis MD, MPH

Background

• Goal: To achieve 70% hypertension control across both our General Internal Medicine practices.

• Strategy: Five evidence-based domains with 1-3 strategies each

• Setting• Anschutz Internal Medicine ~ 4,700

• Lowry Internal Medicine ~ 2,400

Results

33%

63%

67%

37%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

February, 2016 June, 2017

Anschutz Internal Medicine

Providers with 70% Control or Greater

Providers with Less than 70% Control

27%

88%

73%

12%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

February, 2016 June, 2017

Lowry Internal Medicine

Providers with 70% Control or Greater

Providers with Less than 70% Control

EDUCATION

Patient Education Materials Quarterly BP Measurement Technique Trainings

• Medical Assistants (MAs) participate in ongoing educational sessions

• Includes:• Overview of BP• Cuff sizing• Patient positioning• Automatic BP machines• Manual readings

Previous outreach criteria:• Patients age 18-59

• Last BP > 140/90

• Average of the last 3 BP Readings > 150/90

• Last PCP visit 6 months ago or longer

Expanded outreach criteria:

• Patients age 18-59

• Last BP >140/90

• Average of the last 3 BP readings > 140/90

• Last PCP visit 3 months ago or longer

269

504

280

95

0

100

200

300

400

500

600

700

Lowry (n=549) Anschutz (n=599)

Outreach Results

Attempted Resulted in Visit

OUTREACH

Anschutz

• Pharmacy

• Recheck & review

• Encourage Self-monitoring

Lowry

• Physician paired with a trained RN

• Collaborate & manage complex hypertensive patients

• RN provides education & support via telephone / MHC

• Recheck & review

AHA HBP Algorithm Including:• Patient education• Medication titration• Lifestyle modifications

TREATMENT &

COUNSELING

SELF MONITORING

No Co-Pay BP Checks Home BP Checks

• Encouraged self-monitoring as part of treatment via the MD/ RN HTN clinic and the Pharmacy HTN clinic

Summary n %Total # no-charge BP Checks 94# Unique patients 84BP =< 140/90 57 60.6%Escalated to RN 32 34.0%Escalated to MD 2 2.1%Sent to ED 1 1.1%

CURRENT FACULTY # Pat

ients

age

18<=

59

# w

ith B

P <= 1

40/90

# pts

unco

ntrolle

d#

additi

onal co

ntro

lled p

ts to

mee

t goal

% <

= 140

/90

Goal

Johnson, Michelle 20 16 4 - 80.00% 70.00%

Jordan, Michael 87 69 18 - 79.31% 70.00%

Doe, Jane 12 9 3 - 75.00% 70.00%

Test, Doctor 33 24 9 - 72.73% 70.00%

Lee, NP 11 8 3 - 72.73% 70.00%

Green, Mario 57 41 16 - 71.93% 70.00%

Red, Allison 14 10 4 - 71.43% 70.00%

ALL 796 538 258 20 67.59% 70.00%

Diaz, Director 77 52 25 2 67.53% 70.00%

Day, Dean 91 61 30 3 67.03% 70.00%

Physician, Miss 24 15 9 2 62.50% 70.00%

RESIDENTS 144 88 56 13 61.11% 70.00%

Last, First 61 37 24 6 60.66% 70.00%

Name, Name 12 6 6 3 50.00% 70.00%

AUDIT & FEEDBACK

LOWRY IM OP TEST, DOCTOR NO TEST, PATIENT 888888 53 12/11/2015 06/16/2015 152 96 132

LOWRY IM OP TEST, DOCTOR YES JOHNSON, TEST 222222 62 6/24/2015 09/09/2014 133 80 144

LOWRY IM OP TEST, DOCTOR YES DOE, JANE 131313 68 6/17/2015 06/17/2015 138 75 143

# Patients with HTN: 3

# Patients with last BP <= 140/90 2

% Patients with last BP <= 140/90 66.67%

Last Practice Visit

Last

PCP

Visit

Last

BP

Systolic

Last

BP

Diastolic

Average

BP

SystolicDepartment Provider

BP <

140/90

Patient

Name

MRN Age

AUDIT & FEEDBACK

54.55%

50.89%51.72%

57.63%56.14%

52.78%

57.02%54.10%

61.11%

68.24%

71.71%

56.39%

60.33%58.90%

57.96%

62.62%

56.02%

52.17%53.61%

59.73%

61.75%

66.07%

40.00%

45.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

Feb-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun '17

Resident Hypertension Control (Ages 18-59)

LOWRY RESIDENTS ANSCHUTZ RESIDENTS

Uncontrolled Patients: A Deep Dive

144, 83%

29, 17%

Hypertensive Patients with Uncontrolled BP (N=173)

Uncontrolled patients who are NOT actionable

Uncontrolled patients who are actionable and may benefit from anintervention

47, 33%

35, 24%

28, 19%

14, 10%

13, 9%

4, 3%

2, 1%1, 1%

Reasons Patients Were Not Actionable (N = 144)

BP is adequately controlled in Primary Care/ home measurement

Patient did not follow up

Provider is actively intervening on patient. (lifestyle modifications or med titration)

Following PCP's most recent intervention, BP is now controlled

Medication non-adherence

Other medical issues have taken priority

No longer a patient with this provider/ clinic

Patient refused intervention

In Summary

• Push individualized bi-monthly data to providers

• Focused work with residents

• Patient education materials

• Training for MAs

• Outreach

• AHA HBP Algorithm

• No co-pay BP checks

• Home BP monitoring

Lessons Learned

• Pursue improvement in multiple domains

• Monitoring the multiple data streams used to support hypertension improvement is key for improvement work

• Accurate panel attribution is imperative

• Pushing actionable patient-level data is a meaningful exercise

Future Applications for Population Health

Providers receive

actionable patient-level

data

DashboardAutomated process

to push data

Discussion