Population Hypertension Control in the Accountable Care Organization

Health Services Quality Improvement Methods MPH 0231 Spring 2013

Presentation Outline

• Background• Pre-work: – Team, stakeholders, etc.– Shared knowledge etc.

• Charter • QI tools • Project plans• PDSA cycle• Reflection

Introduction

• Hypertension (HTN) is responsible for one in six deaths among adults– most common reason for office visits and prescription

drugs in the United States• Nearly one in three adults has hypertension– huge economic demands on health care(estimated

$73.4 billion)• NHANES survey – 46 to 51% of persons with hypertension control (BP

<140/90)

Barriers to Care

Poor BP Control

Poor access to health care

and medications

Lack of adherence with long-

term therapyPoor

understanding of diagnosis

Population-Based Policy and Systems Change Approach - IOM

Prioritizing Population-

based Strategies

Healthy Lifestyle

Decreased Sodium Intake

Improved Surveillance

and Reporting

Increased Physical Activity

Population-Based Policy and Systems Change Approach - IOM

Promote policy and system change approaches

Treatment according to guidelines

Remove economic barriers to receiving

medications

Provide dietary and physical

activity counseling

Stakeholders for QI TeamStakeholder Groups

Role Why? Unique perspective?

Patient Team Member Inform strategies for behavior change among this population.

Primary Care Physician

Team Member Knowledge of patient condition, patient medical history, treatment options, standards of care.

Nurse Team Leader Knowledge of patient condition and care, hospital operations.

QIOfficer

Team Member/Subject Matter Expert

Unbiased perspective, experience with QI process

ACO Leadership

Sponsor Wants to control population hypertension, needs to meet high quality standards of care while controlling costs for the ACO.

Health Educator

Team Member/Subject Matter Expert

Expertise in educating patients.

Team Roles and ResponsibilitiesTeam Member Role Responsibility

Mio Various roles will be shared

Lead/Scribe for Stakeholder, Team Agreement, Shared KnowledgeShared knowledge task: Change Strategies at the population level

Hee-Jae Various roles will be shared

Lead/Scribe for 3 QI, Charter, PDSAShared knowledge task: Measures of population HTN management

Lauren Various roles will be shared

Finalize PowerPoint presentationShared knowledge task: What population health means for an ACO

Monica Various roles will be shared

PresenterShared knowledge task: Benchmark 3 hospitals in MA using Hospital Compare

Jay Various roles will be shared

PresenterShared knowledge task: Definition of HTN, prevalence, risk factors at population level

Ground Rules

Open communication Be respectful No ego

No yelling Adopt same goals Have trust

Be supportive

Hypertension Control Goals of Accountable Care Organization (ACO)

To control health care costs

Drive quality in health care

Improve population health*

• Improving medical care for their populations of patients!• Attention not focused on social and public health issues

and socioeconomic factors

Flowchart diagram

Cause and effect diagram

Root cause analysis diagram

QI TOOLS

Process Improvement PlansDoes the patient

uncontrolled hypertension

?

Provider educates and engages patient on hypertension self-

management

Follow-up with patient periodically on the progress of

hypertension self-management

Is the patient's BP controlled

under 140/90 mmHg?

Continue to follow-up periodically until next patient

visit

NO

NO

Check out

Schedule a clinic visit

Patient visits the clinic

YES

YES

What is the root cause?

Patients don't know how to control hypertension/non-compliant

They don't have the knowledge/ability they need to do it.

Ineffective communication and non-standard training by provider.

Providers assume that patients understand hypertension management plan.

Patients don't express when they don't understand.

There is no protocol for verifying comprehension.

Problem: Uncontrolled hypertension (BP>140/90 mmHg) in the ACO population

ACTION: Set standards for communicating with patients regarding hypertension self-management

Problem: Ineffective communication between providers and patients regarding hypertension self-management methods

Change Strategies

Producer/customer interface

Exit interview to check comprehension

Sources• Telemed J E Health. 2011

May;17(4):254-61. doi: 10.1089/tmj.2010.0176. Epub 2011 Apr 10

• HHS service report

Focus on variation

Standardize the process of patient’s recording of blood

pressure

Sources• Telemed J E Health. 2013

Apr;19(4):241-7. doi: 10.1089/tmj.2012.0036. Epub 2013 Mar 19

Focus on error proofing

Send out reminders to patients and

checklist for nurses

Sources

Charter

Process Measure• Number of patients who received intervention • Denominator: # of patients with hypertension visited• Numerator: # of patients who received intervention

Outcome Measure• Number of patients with controlled hypertension will be measured• Denominator: # of patients with hypertension diagnoses• Numerator: # of patients with hypertension diagnoses with BP<140/90

Balancing Measure• Provider’s time take away from care will be measured• Denominator: Average patient wait times before PDSA implementation• Numerator: Average patient wait times during PDSA implementation

By 12 months from now, 80% of patients between the age 35-70 with diagnosed hypertension will have BP under 140/90 mmHg.

Plan-Do-Study-Act

Objective: Provider will engage 5 patients and/or caregivers per day for 2 weeks in hypertension self-management methods during patient visit and verify the status of understanding before proceeding to checkout.

Cycle durationMay 6 -20, 2013

Prediction:80% of the patients and/or caregivers will demonstrate their understanding of hypertension self-management methods

Implementation and Measures

After patient’s visit with the physician, nurse’s aid engages patient and/or caregiver in

hypertension self-management methods including:

Medication regimenDiet modification

Increasing physical activities

Outcome measures: Denominator: # of patients receiving hypertension self-

management methodsNumerator:# of patients correctly verbalizing hypertension

self-management to nurse’s aid

Process measures: Denominator: # of patients receiving hypertension self-

management methodsNumerator: # of patients confirming the completion of

hypertension self-management methods upon check-out

Balancing measures:

Denominator: average # of minutes of patient wait times on non-PDSA days

Numerator: average # of minutes of patient wait times on PDSA days.

TEAM REFLECTIONS

• Usefulness of QI tools in pinpointing problems• Importance of patient perspective in designing interventions

Lessons learned

• Different perspectives pulled us in different directions

Barriers to success

• Different perspectives strengthened our final direction

Factors promoting success