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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) ? |
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What are infrastructure characteristics of your health center (use of expanded care team, culture)? | Expanded care team includes Program Coordinator, Community Health Worker and Nurse |
How do interventions and/or workflows need to be adapted to ensure health equity? | Standardized SMBP workflow has been created to address health equity needs. Not all BP cuffs provided to patients were validated devices. The clinic is working to replace all BP cuffs with validated devices |
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)? | |
What are key characteristics of the participating setting(s)? | |
External Characteristics | |
What external or environmental supports or threats are there? | Medicaid redetermination |
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: registry lists of patients with uncontrolled htn on no or monotherapy and determine what intervention would be (e.g., script for patient to intensify medication, use Simplify your Pill Routine cards, other intervention that will focus on intensifying medication) Plan for intervention: have been validating and analyzing patient level data (ensure provider has seen patient, uncontrolled patients on no or monotherapy), put into dashboard to examine trends, choose a provider to pilot, may share at provider meeting with visual | Chosen Intervention: Focus on patients on no or monotherapy Date when implemented: January 1, 2024 Updates: Reviewed the plan with health center leads. Currently working through patient list on no therapy to identify cohort of patients to focus. 2/21/2024: Trying to leverage SMBP program and looking at how it is impacting BP outcomes for patients who are using SMBP vs. those who do not. Provider champion presented to all providers on standardized SMBP workflow on 2/27/2024. Training sessions conducted with various groups throughout the organization. Topics included: Types of medication, medication adherence, medication intensification, and overview of HTN importance and education.
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Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 15-20 providers | Reach of implementers/providers? Actual: |
Reach of patients (# of patients receiving treatment intensification)? 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? looking at data on this group of patients to see if they had their medication intensified (can chart audit) | Were you able to accurately measure how your intervention was working? Champion provider and program coordinator review monthly data |
What outcomes do you expect? look at number of appointments coming in for the month and determine a reasonable goal based on n, will do chart audits after the appointment to determine the result, also want to see if accidentally prescribing monotherapy. Goals will be increased as have success | What outcomes have you seen? We have seen an increase in patients who received medication intensification from 19.7% in July 2023 to 26.7% in April 2024 |
How will you ensure your intervention will be effective for your target population? that patient does have the recommended medication prescribed | Did your intervention reach the target population? Yes, standardized workflow has been shared with all providers. The team has been working to expand SMBP program to cover all patients with uncontrolled HTN |
What unintended consequences or outcomes might there be? might have prescription, but will adherence be an issue, and won’t be able to look at this until subsequent visit | What unintended outcomes did you experience? Providers were reluctant to prescribe single pill combo therapy as they believed most meds were not covered by insurances. We believe this may be due to providers not aware of current coverage availability. We have since provided clinical team with resources that show coverage for most meds within IL. Clinical team will educate all providers. |
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? Director of Clinical Innovation, MD Program Coordinator, MD |
How will you know if clinicians/care teams/sites used the intervention? | 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? Modifications will be discussed during monthly check-in meeting with project leads | How did you track modifications during the intervention? |
What might be some of the possible obstacles to consistent implementation? Limited staff time to support the expansion of SMBP | What were the barriers to consistent intervention implementation? Currently the SMBP portal used by patients to report home monitored BP is not integrated into the EHR resulting in program coordinator spending extensive amount of time to review results in portal and document in the EHR. We are working on the system integration that will allow for more widespread implementation of SMBP |
What costs and resources (including time and burden, not just money) need to be considered? Program Coordinator time to review reports, validate and make necessary changes. Running the SMBP program involves extensive time to educate and enroll patients, monitor/document patient reported BP through a third party system that is not currently integrated into EHR. | 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? Results and lessons learned to be shared through internal provider meetings | 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: Improve patient engagement and increase frequency of follow-up visits Plan for intervention: Based on cohorts of patients identified (patients on no therapy and patients on monotherapy), Patient coordinators will contact patients and schedule for follow-up visits; in office, Telehealth. Assist patients identified for SMBP in obtaining BP measurement devices and educate patients on home BP monitoring. | Chosen Intervention: Date when implemented: Updates: |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 15-20 providers | Reach of implementers/providers? Actual: |
Reach of patients (# of patients receiving treatment intensification)? 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? Regularly scheduled check-in calls with program coordinator to monitor status of patient outreach | Were you able to accurately measure how your intervention was working? |
What outcomes do you expect? Increased frequency of patient follow-up and/or increased frequency of BP measurements | What outcomes have you seen? |
How will you ensure your intervention will be effective for your target population? Outreach to patients in cohort | 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. | 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? | 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:
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)? | |
| Version | Date | Comment |
|---|---|---|
| Current Version (v. 12) | May 09, 2024 19:24 | Varun Venkateswaran |
| v. 11 | May 09, 2024 19:02 | Varun Venkateswaran |
| v. 10 | Apr 30, 2024 17:06 | Varun Venkateswaran |
| v. 9 | Mar 18, 2024 19:15 | Varun Venkateswaran |
| v. 8 | Feb 21, 2024 19:47 | Meg Meador |
| v. 7 | Feb 20, 2024 20:34 | Varun Venkateswaran |
| v. 6 | Jan 05, 2024 16:41 | Lauren Becker |
| v. 5 | Dec 20, 2023 18:36 | Varun Venkateswaran |
| v. 4 | Nov 16, 2023 17:37 | Varun Venkateswaran |
| v. 3 | Nov 13, 2023 16:38 | Varun Venkateswaran |
| v. 2 | Nov 13, 2023 16:36 | Varun Venkateswaran |
| v. 1 | Sept 18, 2023 18:04 | Lauren Becker |
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