City of Cincinnati Intervention Assessment

Internal Characteristics

What are the characteristics of your health center? (rural/urban; other demographic variables)?  

Urban FQHC that serves over 40,000 patients annually. Last year 56% of pts were black/AA and 28% reported being Hispanic.

What are the infrastructure characteristics of your health center (use of expanded care team, culture)?

Use expanded care team. Our organization engages in ongoing QI work to ensure quality, safety, and value for our patients, and we have an organizational commitment to QI capacity.

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

For the purposes of this project, we continue to utilize the patient details list to determine / drive how we are implementing and delivering our interventions. This is to ensure that we are targeting our AA patient population and improving health equity in our health centers.

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)?

The interventions we have selected are:

• to continue to use the patient detail list to target (no therapy, active patients, uncontrolled HTN) to message utilizing our WELL bidirectional software to encourage patients to see their PCP and/or the clinical pharmacy team (data-driven patient outreach)

• we are continuing to assist patients with obtaining validated, automated home BP measurement devices with appropriately-sized upper arm cuffs to improve patient engagement

The interventions are not super complex because we are able to use the patient detail list as well as some in-house data to drive these interventions. Additionally, we have already established the protocols for ordering a BP cuff for our patients directly through the pharmacy. So the amount of steps and disruptiveness for these interventions is reduced.

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

Urban FQHC that serves over 40,000 patients annually. Last year 56% of pts were black/AA and 28% reported being Hispanic. Use expanded care team. Our organization engages in ongoing QI work to ensure quality, safety, and value for our patients, and we have an organizational commitment to QI capacity.

External Characteristics

What external or environmental supports or threats are there?

Some of the identified external or environmental threats are difficulties experienced with our patients in regards to transportation & ability to pay.

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: Using WELL (bi-directional texting option) to decrease no therapy

Plan for intervention: Text to patients on no therapy to seek out appointments with clinical pharmacy team (more openings)

Thinking of repeating this with Monotherapy.

Chosen Intervention: Using WELL (bi-directional texting option) to decrease no therapy

Date when implemented: ETA - Feb 2024, April 2024, June 2024

Updates: Received permission from CMO & Medical Director to push these text messages to patients that have opted in. Working on drafting text messages. Will send to patients from the January 2024 Patient Detail List. Plan to repeat bi-monthly, and/or repeat with individuals who are uncontrolled on monotherapy.

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

Reach of implementers/providers?

Planned: Send texts to wide group of patients. They will be sent to uncontrolled HTN no therapy, individuals on monotherapy

Reach of implementers/providers?

Actual:

Reach of patients (# of patients receiving treatment intensification)? 36 patients needs addressed through utilization of list/data/WELL combo.

Planned:

• # AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023):

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023):

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? Using WELL to decrease no therapy -> look at % of patients who were on therapy 6 months after each of the text messages are sent

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

What outcomes do you expect? Decrease the number of patients with no therapy, appointments generated from the texts would increase.

What outcomes have you seen?

How will you ensure your intervention will be effective for your target population? Planning to send the text bi-monthly or monthly to ensure action.

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. The texts would be sent automatically and the list of patients will come from the patient detail list, filtered by criteria mentioned above. One staff member will create the patient lists for the texts to be sent to, and the messages will be sent by another staff member who oversees our WELL software.

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?

Working directly with staff member who is sending the texts via WELL. If any changes or modifications are made to this intervention, we both will be informed.

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation? Automation will help with any obstacles.

What were the barriers to consistent intervention implementation?

What costs and resources (including time and burden, not just money) need to be considered? Not much burden on staff because once the list is created the texts will be sent automatically.

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: If the intervention is effective, a regular report with the patient details would need to be ensured. Also, a standard protocol for generating the patient lists for each of the text messages, as well as timing for the sending of these messages would need to be created.

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?

QI Steering Committee Meeting, OCHIN Learning Forum, internal QI 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: BP Cuffs

Plan for intervention: Place order for additional BP Cuffs. Make validated BP cuffs available to patients

Chosen Intervention: Assisting patients with BP cuffs -> 150 patients

Date when implemented: 208 additional BP cuffs were ordered on 10/27/2023. These cuffs were distributed to our pharmacies for eligible patients.

Updates:

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

Reach of implementers/providers?

Planned: Place orders for new BP cuffs for patients. All providers can order from any of the pharmacies within our system.

Reach of implementers/providers?

Actual:

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

Planned: 150 patients

• # AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023):

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023):

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? Order placed in the patient’s chart.

Were you able to accurately measure how your intervention was working? Assisting patients with BP cuffs -> Number of blood pressure cuffs dispensed to our project population through the pharmacy

What outcomes do you expect? Better BP control with home use.

What outcomes have you seen?

How will you ensure your intervention will be effective for your target population? There is follow up with the patient (e.g., follow-up appt scheduled within 4 weeks).

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. Widespread effort across all 6 sites and providers. The BP cuffs are available at all 6 of the pharmacies.

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? Track through orders placed.

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? This implementation is remaining true to previously successful implementations.

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation? Since this has been previously implemented, there are no potential obstacles from the side of staff/sites.

What were the barriers to consistent intervention implementation?

What costs and resources (including time and burden, not just money) need to be considered? Re-using previously created criteria to share with providers

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)?