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Important Health Center Context Fill out this section during your planning process | |
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Internal Characteristics | |
What are the characteristics of your health center? (rural/urban; other demographic variables, use of expanded care team, culture)? | most pts are Black/AA or Hispanic; @ WOH site primarily AA; East Oakland primarily Hispanic (most HTN between these two groups); high # of homeless pop - challenging to keep in outreach |
What are the infrastructure characteristics of your health center (use of expanded care team, culture)? | community health dept handles outreach - hired health coach to utilize as educator (more focused on outreach and engagement than in clinic work) |
How do interventions and/or workflows need to be adapted to ensure health equity? | lean on community health dept a lot to incorporate equity - help to identify barriers for pts - work with underprivileged communities so find ways to help pts prio health (e.g., need healthy food, provide gift cards, education, transportation) |
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)? | main barrier is understaffing which makes all workflows much harder to implement - saw the impact of this on most of their measures; provider schedules also adds to perceived difficulty - pts feel appts are so far away (TIME -appt availability - offer appt a few months out) that they end up not wanting to come in; BP clinic is helping to relieve that wait time and can address some of these concerns with a fully staffed community health dept and new providers currently onboarding |
What are key characteristics of the participating setting(s)? | having an in-house pharmacy at WOH has been an enabler for medication-related interventions as it relates to HTN; BP clinic set up is also unique to WOH and can help with BP compliance |
External Characteristics | |
What external or environmental supports or threats are there? | |
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: Having a provider champion train clinicians on guideline-supported treatment algorithms Plan for intervention: Provider champion (Dr. Vanessa Grubbs) will help train and educate new providers on treatment algorithms to speed up the onboarding process and will refresh knowledge sharing efforts for existing provider group; the plan is to have her help new clinicians become aware of existing workflows and get them quickly up to speed; she will essentially be in communication with providers to help bridge the information gap; cadence and structure of training will be determined, but she will begin joining internal meetings to discuss HTN workflows and any needed workflows changes | Chosen Intervention: provider champion for clinician training on guideline-supported treatment algorithms Date when implemented: August 2023 Updates: 12/20/24 - meeting tomorrow for updates still trying to communicate with new clinicians, CHCN will be getting facetime to see how this works right now mono is still first - trying to move this to SPCT 2/26/24 - workflow has been updated; NP Kim will be clinician champion mostly seeing patients who are disconnected from care to review status of HTN treatment, medication, and overall health; health educators will then provide after visit education which includes information on how to improve BP, log medication, prep for appointments, and resources for SDOH-related needs that have been identified - this is a “tag team” approach between clinician and CHA team |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 9 providers (includes provider champion) | Reach of implementers/providers? Actual: 1 provider (NP Kim), 1 RN (Anekaila Crevani), 1 CHA, 1 health coach/educator (Liviier Lara) |
Reach of patients (# of patients receiving treatment intensification)? Planned: 70/556 (no therapy) and 164/556 (monotherapy)
| 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?
| Were you able to accurately measure how your intervention was working? QI team runs a report to compare the state of the patient at initial visit and follows the patient’s progress for 3 months - this includes multiple metrics/measures: overall BP, HTN prescription and dosage, connection to social care resources after SDOH screening |
What outcomes do you expect? At least 80% of providers adhere to HTN workflow and treatment protocol; consider looking at prescriptions by panel by provider (e.g., provider scorecard) to understand who is prescribing monotherapy, combo therapy, SPC, etc. | What outcomes have you seen? It is still early after pivoting to a new workflow, but the hope is that by addressing patient’s HTN needs (medical) including meds, with social needs (e.g., transportation has been identified a barrier to HTN treatment and care), BP is more managed and pts feel more empowered to take charge of their own health / improve their BP |
How will you ensure your intervention will be effective for your target population?
| Did your intervention reach the target population? Yes, we are reaching AA adults, particularly those disconnected from care with CHA outreach calls |
What unintended consequences or outcomes might there be?
| What unintended outcomes did you experience? Staffing is a tremendous challenge at WOHC, making implementation of provider-led interventions for HTN particularly hard |
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.
| Who delivered the intervention? Did they have the skills and time needed to complete the intervention? NP Kim, CHA team, health educator - yes having a clinician and community health advocate tag team will be incredibly helpful for a “holistic” approach to managing BP |
How will you know if clinicians/care teams/sites used the intervention?
| What proportion of the planned staff/sites implemented the intervention? About 20-30% of planned staff are taking part in intervention, so much lower than anticipated; this will be conducted on a smaller scale than planned 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? During internal meetings and huddles (cadence?) staff delivering the intervention can review data and discuss collectively how to adjust/pivot if necessary; Dr. Grubbs can also take feedback on implementing treatment algorithm, document any changes, and share back with the group involved in delivery (e.g., Anekaila, Kemberly, provider group) | How did you track modifications during the intervention? |
What might be some of the possible obstacles to consistent implementation? Ensuring sustainability of the guideline-supported treatment algorithm Dr. Grubbs is implementing; ensuring that prescription behavior change for providers “sticks” and continues beyond a 90-day mark; ensuring that documentation on med intensification is consistent in the EMR | What were the barriers to consistent intervention implementation? |
What costs and resources (including time and burden, not just money) need to be considered? There will be a big upfront time investment for Dr. Grubbs to train existing and new providers on workflows and ensure sustainability with consistent check-in calls or team huddles; there is an opportunity cost to training – it could pull clinicians away from other tasks and responsibilities. This could be particularly challenging with clinic staff capacity issues. WOHC continues to hire provider and RN staff so we can closely monitor the impact of this initiative on staff workload/capacity. | 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:
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?
Explain: | What reinforcements did you put into place to sustain the intervention?
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: targeted patient outreach messaging using MyChart bulk communication feature and central phone calls Plan for intervention: WOHC plans to use central phone calls and bulk communications to reach out to patients. They will be targeting patients who need to come in for a visit who have not been engaged in care. For noncompliant patients, the plan is to send them information about resources and community health offerings through educational flyers. If a patient replies to a MyChart message their reply will go directly to a Community Health (CH) advocate who will then contact them to discuss appointment scheduling and resources over the phone, including SMBP. For patients with an appointment scheduled, messaging will be used to send them a reminder. The CH team will develop separate messaging for Million Hearts patients after pulling a patient list from WorkBench. Separate, culturally competent educational materials will be created for this population. | Chosen Intervention: targeted patient outreach messaging using MyChart bulk communication feature and central phone calls Date when implemented: September/October 2023 Updates: |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: | Reach of implementers/providers? Actual: |
Reach of patients (# of patients receiving treatment intensification)? 70/556 (no therapy) and 164/556 (monotherapy) Reach of patients (# of patients noncompliant BP)? 556/1437 *numerator is number to target for this intervention Planned:
| 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? We will measure impact on overall BP control measure (AA Adults BP Control (past 12 months)); CH team can also track a subset of all noncompliant patients by analyzing the BP reading data for patients on outreach lists who reply to a MyChart message and schedule an appt. The team can also track the “no show” rate for these patients to see if outreach and scheduling is effective. We will also track number of patients on no HTN medication. | Were you able to accurately measure how your intervention was working? |
What outcomes do you expect? We would expect BP control to increase for patients responsive to outreach and who schedule an appointment. We may also see a decrease in the number of patients on no HTN medication if patients newly engaged in care are coming into the clinic for a visit. | What outcomes have you seen? |
How will you ensure your intervention will be effective for your target population?
Community health advocate (CHA) will also be tracking patient’s BP after every visit with provider so can see impact on MH population; QI team will generate lists of patients with recent visits and review whether they are on anti HTN medication or not – the goal is that the number on no anti HTN from MH patient list will be decreasing. | Did your intervention reach the target population? |
What unintended consequences or outcomes might there be?
| 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. QI team will create list of AA HTN pts who have not had a visit in the measurement period and pts on no anti HTN medication without a visit in the measurement period; Community Health Advocates (CHA) will identify patients with active MyChart accounts and send informational flyers to pts; this will happen across sites | 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? CHAs and QI team will communicate to check in on the intervention and their ability to work through outreach lists; will also discuss the engagement rate and no show rate at team 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? CHAs meet monthly to discuss existing projects - Laura presents data to them that is relevant to project and overall HTN rate - can discuss barriers to interventions that need to be addressed and will pivot if needed | How did you track modifications during the intervention? |
What might be some of the possible obstacles to consistent implementation? Staff outreach capacity - one CHA currently and thinking through how to best utilize her team to have implementation work ongoing at both sites Pt engagement - # of responses from outreach messaging (want pt to continue to work with health coach and create small goals to keep them engaged - thinking of f/u strategies to make sure they remain engaged - considering a screening for SDOH to address barriers to coming in for appts (e.g., transportation) | What were the barriers to consistent intervention implementation? |
What costs and resources (including time and burden, not just money) need to be considered? Up front time commitment for outreach and engagement; using budget for some “swag” to keep patient engaged | 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:
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?
Explain: training necessary since WOHC is piloting this → ultimate goal of sustaining through a formal workflow | What reinforcements did you put into place to sustain the intervention?
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)? | |
| Version | Date | Comment |
|---|---|---|
| Current Version (v. 12) | Feb 28, 2024 16:58 | Hallie Roth (Unlicensed) |
| v. 14 | Feb 28, 2024 18:11 | Hallie Roth (Unlicensed) |
| v. 13 | Feb 28, 2024 17:48 | Hallie Roth (Unlicensed) |
| v. 12 | Feb 28, 2024 16:58 | Hallie Roth (Unlicensed) |
| v. 11 | Jan 17, 2024 21:52 | Hallie Roth (Unlicensed) |
| v. 10 | Jan 05, 2024 16:43 | Lauren Becker |
| v. 9 | Jan 03, 2024 20:57 | Hallie Roth (Unlicensed) |
| v. 8 | Dec 20, 2023 18:52 | Chris Espersen |
| v. 7 | Dec 20, 2023 17:30 | Hallie Roth (Unlicensed) |
| v. 6 | Nov 08, 2023 23:56 | Hallie Roth (Unlicensed) |
| v. 5 | Nov 01, 2023 18:37 | Hallie Roth (Unlicensed) |
| v. 4 | Oct 25, 2023 18:51 | Chris Espersen |
| v. 3 | Oct 11, 2023 00:32 | Hallie Roth (Unlicensed) |
| v. 2 | Sept 20, 2023 03:01 | Hallie Roth (Unlicensed) |
| v. 1 | Sept 18, 2023 20:04 | Lauren Becker |
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