Western Wayne Intervention Assessment

Internal Characteristics

What are the characteristics of your health center? (rural/urban; other demographic variables, use of expanded care team, culture)?  

Western Wayne Family Health Centers’ area population are the low-income (125,259 individuals/ 47.66% of the population) the underinsured, and the uninsured. Approximately 13.28% of the low-income in the service area presently utilize the services of a FQHC. The service area has a disproportionate number of poor residents, reflected in a high unemployment rate, low educational levels, and a resulting lack of mobility. Black/African Americans (22.05%) and Hispanics (7.89%) comprise the greater part of the 35.11% of the racial/ethnic minority population. There also are a significant number of residents of Middle Eastern descent, living primarily in the Dearborn zip codes. Our service area includes the communities of Inkster, Taylor, Lincoln Park, Dearborn, Dearborn Heights, Romulus, River Rouge, Ecorse, Southgate, and Southwest Detroit, all of which are in southwest Wayne County and are part of the Detroit Metropolitan Statistical Area. The service area communities comprise approximately 122 square land miles and are considered a part of the Detroit metropolitan area that has been labeled the "Downriver Community." The communities are closely linked with the rise and fall of the fortunes of Detroit.

How do interventions and/or workflows need to be adapted to ensure health equity?

Our goal with any intervention focused on improving the health outcomes of our patients is to ensure that all patients who fall under the hypertensive measure benefit from this intervention. We have seen much success in our hypertension management for our patients in the Million Hearts cohort, so we expanded our intervention to include all patients with hypertension management to ensure they benefit from this opportunity

How complex are the patient interventions to implement (e.g., perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, and number of steps required)?

Our current patient intervention focusing on medication intensification is quite difficult due to many barriers in implementation, including provider readiness, patient hesitancy, and provider and patient buy-in. It requires intensive provider education efforts such as speakers at the provider meeting, presenting data audits of finding, sharing successful case studies. Furthermore, it requires patient buy-in and increase in patient’s self-efficacy which take time.

What are key characteristics of the participating setting(s)?

Key characteristics of the Western Wayne’s area of service is that there are approximately 262,784 residents, nearly half-125,259 (47.66%)-are considered low income, living at or below 200% of the federal poverty level. Approximately 32.96% residents receive Medicaid or other public insurance benefits.2 An estimated 7% of residents (18,394 people) are uninsured. Persons age 65 and older comprise 15.8% of the population.

External Characteristics

What external or environmental supports or threats are there?

Environmental Supports: Recent addition of Community Health Workers to our team has made a significant improvement in our quality metrics such as hypertension management. One reason being is that our CHWs are from the community and have a deep understanding of the challenges of the residents which allows them to build rapport and provide much needed guidance and support in managing their health conditions.
Environment Threats: Service area residents have long struggled with access to reliable public transportation to keep their health care appointments.

Treatment Intensification (Combination Therapy)

Plan

Treatment Intensification (Combination Therapy)

Actual

Describe Intervention

(Select ONE; use BPAA Project Roadmap for ideas on evidence-based strategies)

Chosen intervention: EMBED ALGORITHM INTO CARE PROCESSES.

Plan for intervention: Engage clinicians across the organization in the develop of a treatment protocol for hypertensive patients and pilot implementation of the protocol.

Chosen Intervention:

Date when implemented:

Updates: 12/18 -

Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention)

Reach of implementers/providers?

Planned: 18 Providers

Reach of implementers/providers?

Actual: 12/18 - starting with 1, will eventually reach all

Reach of patients (# of patients receiving treatment intensification)?

1. 50% of patients from HTN no therapy to guideline therapy.

Goal: 41 patients with uncontrolled HTN on no therapy to monotherapy or combination therapy.

2. 50% patients from HTN on monotherapy to guideline recommended therapy.

Goal: 70 Patients with uncontrolled HTN on monotherapy to combination therapy.

Baseline Data (as of 6/30/2023):

• # AA pts. w/uncontrolled HTN on no therapy: 82/502

• # AA pts. w/uncontrolled HTN on monotherapy: 141/502

Reach of patients (# of patients receiving treatment intensification)?

Actual: initially, ~50% of planned patients

want to reach no therapy and monotherapy

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

Assess Providers barriers and successes through surveys and discussions during Provider meetings; Monitor Dr. Malcom’s patients during the pilot. Monitor PVP alert closure per AMA cohort.

NOTE: NACHC glad to assist with survey methodology

Were you able to accurately measure how your intervention was working?

What outcomes do you expect?

Standardized protocol for all Providers throughout Western Wayne.

What outcomes have you seen?

How will you ensure your intervention will be effective for your target population?

Monitor process and outcome data within the Million Hearts Scorecard in Azara, as well as individual Provider scorecards.

Did your intervention reach the target population?

What unintended consequences or outcomes might there be?

Provider apprehension

What unintended outcomes did you experience?

Adoption (#/% and representativeness of staff and sites who implemented the intervention)

How did clinicians respond to interventions to intensify medication more rapidly/address therapeutic inertia?

Who will deliver the intervention (actually do the work)? Include staff and sites, if applicable.

PRIMARY LOCATION: Inkster - Dr. Latisha Malcom (MD), Medical Assistants (MA), Community Health Workers (CHW), Clinical Supervisors.

PRIMARY PILOT LOCATION: Lincoln Park - Dr. Sanjoy Mukerjee (MD), Medical Assistants (MA), Community Health Workers (CHW), Clinical Supervisors.

SECONDARY PILOT LOCATION: Taylor - Danielle Gertz (NP), Medical Assistants (MA), Community Health Workers (CHW), Clinical Supervisors.

SECONDARY PILOT LOCATION: Dearborn - Dr. Mazraani (MD), Medical Assistants (MA), Community Health Workers (CHW), Clinical Supervisors.

Who delivered the intervention? Did they have the skills and time needed to complete the intervention?

How will you know if clinicians/care teams/sites used the intervention?

Review the change in the measure, AMA MAP BP™ - HTN-Medication Intensification, from baseline provider meeting. Establish touch-base through provider meetings.

What proportion of the planned staff/sites implemented the intervention?

Were there any differences between care teams/sites who adopted the intervention best vs. others who did not (e.g., differences in staff types, capacity, etc.)?

Implementation Fidelity (How closely the staff/sites followed the intervention design, delivered it as intended – also called fidelity to the intervention)

How will you know what adaptations or modifications were made during the intervention?

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation?

What were the barriers to consistent intervention implementation?

What costs and resources (including time and burden, not just money) need to be considered?

What costs and resources (including time and burden, not just money) need to be considered?

How closely did the staff/sites follow the intervention design and deliver as intended?

Check all that apply:

• Followed as designed
• Followed with minor modifications
• Followed somewhat as designed
• Not followed as design
• Delivered consistently/as intended
• Delivered somewhat consistently/somewhat as intended
• Delivered inconsistently/not as intended

Modifications made and other notes:

Maintenance (Extent to which intervention is part of routine practices and protocols)

What reinforcements will you put in place to sustain the intervention, if effective?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

What reinforcements did you put into place to sustain the intervention?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

How will you spread your intervention and lessons learned?

How will you spread your intervention and lessons learned?

What are likely modifications or adaptations that will need to be made to sustain the intervention over time (e.g., lower cost, different staff, reduced intensity, different settings)?

Intervention #2

Plan

Intervention #2

Actual

Describe Intervention

(Select ONE; use BPAA Project Roadmap for ideas on evidence-based strategies)

Chosen intervention: INCREASE TOUCHPOINTS

Plan for intervention: Establish frequent follow-up protocol for patients with uncontrolled hypertension (e.g., 2-4 weeks), including use of telemedicine.

Chosen Intervention:

Date when implemented:

Updates:

Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention)

Reach of implementers/providers?

Planned: Increase follow-up appointments by 50% in patients who have uncontrolled HTN.

Reach of implementers/providers?

Actual:

Reach of patients (# of patients receiving treatment intensification)?

Goal: 96 Patients with Follow-Up After Visit w/uncontrolled HTN.

Baseline Data (as of 6/30/2023):

• # AA pts. Follow-Up After Visit w/uncontrolled HTN: 191/866

Reach of patients (# of patients receiving treatment intensification)?

Actual:

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

Monitor data in the Million Hearts Scorecard in Azara (Follow Up Measure).

Were you able to accurately measure how your intervention was working?

What outcomes do you expect?

Improvement on Uncontrolled HTN on No Anti-HTN Medications reduced by 5%. Goal: 10%.

What outcomes have you seen?

How will you ensure your intervention will be effective for your target population?

Monitor data in Million Hearts Scorecard in Azara; Monitor PVP reports at point of care specific to cohort.

Did your intervention reach the target population?

What unintended consequences or outcomes might there be?

Patient apprehension and appointment compliance.

What unintended outcomes did you experience?

Adoption (#/% and representativeness of staff and sites who implemented the intervention)

How did clinicians respond to interventions to intensify medication more rapidly/address therapeutic inertia?

Who will deliver the intervention (actually do the work)? Include staff and sites, if applicable.

All WWFHC Sites: Providers (MD), Medical Assistants (MA), Community Health Workers (CHW), Clinical Supervisors.

Who delivered the intervention? Did they have the skills and time needed to complete the intervention?

How will you know if clinicians/care teams/sites used the intervention?

Monitor data in HTN Follow-up after visit with uncontrolled HTN-Follow-Up After Visit with Uncontrolled HTN per WWFHC site.

What proportion of the planned staff/sites implemented the intervention?

Were there any differences between care teams/sites who adopted the intervention best vs. others who did not (e.g., differences in staff types, capacity, etc.)?

Implementation Fidelity (How closely the staff/sites followed the intervention design, delivered it as intended – also called fidelity to the intervention)

How will you know what adaptations or modifications were made during the intervention?

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation?

What were the barriers to consistent intervention implementation?

What costs and resources (including time and burden, not just money) need to be considered?

What costs and resources (including time and burden, not just money) need to be considered?

How closely did the staff/sites follow the intervention design and deliver as intended?

Check all that apply:

• Followed as designed
• Followed with minor modifications
• Followed somewhat as designed
• Not followed as design
• Delivered consistently/as intended
• Delivered somewhat consistently/somewhat as intended
• Delivered inconsistently/not as intended

Modifications made and other notes:

Maintenance (Extent to which intervention is part of routine practices and protocols)

What reinforcements will you put in place to sustain the intervention, if effective?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

What reinforcements did you put into place to sustain the intervention?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain:

How will you spread your intervention and lessons learned?

How will you spread your intervention and lessons learned?

What are likely modifications or adaptations that will need to be made to sustain the intervention over time (e.g., lower cost, different staff, reduced intensity, different settings)?