Mercy Care Intervention Assessment

Internal Characteristics

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

Mercy Care is an urban FQHC and is the only Healthcare for the Homeless designated provider in Atlanta.  The organization offers programs and services including primary and preventive health care, dental and vision services, health education focused on chronic disease management and prevention, HIV/AIDS-related services, and integrated behavioral health and substance use programming to thousands of homeless and low-income individuals each year.

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

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

Our interventions consider patients language, culture, and literacy levels and our teams work to meet patients where they are.

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 are a continuations of activities and are not far outside of normal practices.

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

In 2022, Mercy Care served 15,915 patients in 57,696 visits across seven sites. Of those served, approximately 51% were experiencing homelessness, 45% were Black, 37% were Hispanic, 38% were best served in a language other than English, and 53% were uninsured. Among those for whom we have income data, 82% live at or below 100% of the federal poverty level. 

External Characteristics

What external or environmental supports or threats are there?

Supports include new funding for hypertension related activities (as our HRSA NHCI grant period is ending which supported our initial SMBP implementation), community engagement (new Atlanta Hypertension Initiative convened for the first time 10/24 hosted by ARCHI with representation from AMA, Live the Beat, and other community partners), and new leadership at Mercy Care (new President and CMO onboarded in the last few months). Threats may include retention of staff, burnout, competing priorities for providers to address for patients (especially SDH related, stress), patient satisfaction related to scheduling and wait times (may affect patients returning for follow-up visits).

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: Improve patient engagement – Utilize Mercy Care Fall Festival to take patient blood pressures and schedule follow-ups - this is a new process for Mercy.

Plan for intervention:

May add another intervention focused on WellApp bi-directional text messaging for patient outreach for patients on no/mono-therapy. Patients can actually schedule appointments through the text message/app right away.

Chosen Intervention:

Mercy Care Fall Festival to take patient blood pressures and schedule follow-ups

Date when implemented: 10/23

Updates: The Fall Festival was amazing, a great opportunity to connect with patients, educate and check their blood pressures.

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

Reach of implementers/providers?

Planned: Up to 650 attendees based on previous events.

Reach of implementers/providers?

Actual: 670 attended the Fall Festival, 120 more than the prior year.

Reach of patients (# of patients receiving treatment intensification)? At Health Fair - 40 BP checks, 10 here elevated - education opportunity and 6 visits scheduled

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: At Health Fair - 40 BP checks, 10 here elevated - education opportunity and 6 visits scheduled

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working? If patients who are hypertensive schedule a follow up. 1 would be a success.

Were you able to accurately measure how your intervention was working? Have 6 scheduled and attended visits to Mercy Care.

What outcomes do you expect?

What outcomes have you seen? Opportunities for education and improved BP control.

How will you ensure your intervention will be effective for your target population? Adding scheduled visits to the outcomes instead of checking BP as well.

Did your intervention reach the target population? Staff scheduled follow up visits at the festival instead of just checking the BP.

What unintended consequences or outcomes might there be?

What unintended outcomes did you experience? Previously created protocol to address any concerns, patients in HTN emergency range.

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. CMA and Nursing staff will be doing BP checks, there will also be at least one provider available.

Who delivered the intervention? Did they have the skills and time needed to complete the intervention? CMA and Nursing staff did the BP checks, there will also be at least one provider available.

How will you know if clinicians/care teams/sites used the intervention? Whether the patient returns to the office for the scheduled visit.

What proportion of the planned staff/sites implemented the intervention? 7 Medical Assistants, 2-3 assigned to take blood pressures.

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.)? N/A

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? HTN patients are allowed to rest for 5 minutes. No need for EMS at the event.

How did you track modifications during the intervention? They were witnessed and implemented by supervisors. Documentation was updated.

What might be some of the possible obstacles to consistent implementation? This was previously implemented, not expecting obstacles to implementation from the staff/site side.

What were the barriers to consistent intervention implementation? No barriers to this implementation.

What costs and resources (including time and burden, not just money) need to be considered? Staff time out of the physical clinic building. This was a Saturday and staff were paid overtime.

What costs and resources (including time and burden, not just money) need to be considered? No impact on the clinic being open, this was a Saturday. Staff time was the only cost.

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 fun activities at the festival e.g., haircuts, lunch, etc.)
• 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? Internally continue to take this approach at future events. Marketing department helps share the success of the event (number of patients attending, how they were helped, etc.). External and internal communications sent out.

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)? No modifications/adaptations needed. This is a bi-annual event (spring and fall).

Intervention #2

Plan

Intervention #2

Actual

Describe Intervention

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

Chosen intervention: SMBP Program CMO

Possible Intervention #3: update HTN protocol with Primary Care Director Dr. Winzer

Plan for intervention: Using different forms of funding to place new orders for BP cuffs.

Chosen Intervention: Increase touchpoints – Continued follow-up with current SMBP patients who are not controlled

Date when implemented: October 2021

Updates:

2/28/2024: NHCI grantee - past 3 years, SMBP program has evolved; for past year, have included CHWs in cuff distribution and education piece, as well as connecting Bluetooth technology for patients. Providers will refer patients to the program - try to do set up and education on the same day (warm handoff to avoid access barriers). Use teach back method for training and patient materials, including Spanish. More patients who are B/AA than Hispanic - focusing on making sure training is culturally appropriate. Has expanded to additional sites but looking now at how to sustain SMBP without grant funding. Providers review SMBP data for clinical action in between visits or use telehealth. CHWs also are part of Community Resource Hub to help address SDOH needs of pts. with HTN and diabetes and starting to evaluate use.

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)? 140

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: 737 patients have received a cuff, education on how to use it, and help connecting to apps (when applicable).

Created a few different pamphlets for this work. For example, one for bluetooth connection. Staff goes over this pamphlet with patient in clinic. Additionally, bp measurement techniques and manual entry of bp. Lastly, staff had a “cheat sheet” for how to help with the bluetooth connection for patients.

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working? Staff (CHW) does a 1-month f/u with patients to make sure the cuffs are being used properly and to ensure provider f/u when needed.

Were you able to accurately measure how your intervention was working? CHW, patient educator, and nurse all support the patient with a 1 month check in. Developing a process to assure follow ups are being made in a timely fashion.

What outcomes do you expect? Providers will receive the BP in their inbasket if patients are using bluetooth enabled devices.

What outcomes have you seen? Providers receive patients' BP in their inbasket. General feedback from providers is that they enjoy receiving this in their inbasket and feel pride in their patients for following through on this. There is still room for improvement on how many patients have access to bluetooth enabled devices.

How will you ensure your intervention will be effective for your target population? Providers use BP data to make any changes to their treatment plans.

Did your intervention reach the target population? Developing new specifications on who the bluetooth cuffs can be ordered for to assure uptake from the patient. This will make it more likely for patients to be able to submit bluetooth BP data.

What unintended consequences or outcomes might there be? Sometimes the patients don’t use the cuffs or they don’t hear back from patients. Due to the nature of their patient population, they don’t have as much access to technology. Patient compliance is the biggest issue. They use the take-back method to help educate patients and make directions clear.

What unintended outcomes did you experience? Patient compliance remains the issue. Need to set parameters for patients who receive the cuffs to ensure compliance.

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. Pharmacists used to help with implementation/medication review but this is no longer the case. They want to reinstate the pharmacy back into the program. Patient educators and CHWs are giving the BP cuffs and education out currently to patients.

Who delivered the intervention? Did they have the skills and time needed to complete the intervention? In the process of hiring a new clinical Pharmacist who will be more integrated into the care team vs separate Pharmacy staff only.

How will you know if clinicians/care teams/sites used the intervention? There is a report used for MyChart bluetooth BP. There is a flowsheet for paper forms, but this is not used as frequently right now. Most paper forms are scanned in, this workflow is not fully adopted.

What proportion of the planned staff/sites implemented the intervention? 1283 BP readings received electronically – this is for 6% of the patients that receive the cuff.

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? Some modifications include staff that were involved. There were no staff at the beginning for this program.

How did you track modifications during the intervention? Addition of CHWs to the program, included training/onboarding them.

What might be some of the possible obstacles to consistent implementation? Staffing and turnover. Technology barriers for both staff and patients. Language barriers, e.g., no Spanish speaking staff at first although translated materials were available.

What were the barriers to consistent intervention implementation? Staffing and turnover. Technology barriers for both staff and patients. Language barriers, e.g., no Spanish speaking staff at first although translated materials were available.

What costs and resources (including time and burden, not just money) need to be considered? No cost barriers. Resourcing issues due to staff turnover.

What costs and resources (including time and burden, not just money) need to be considered? Ordering directly from the vendor helps with obtaining devices. Need funding to continue to maintain this.

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: This program has been going on for 3 years.

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? Internal and external organization Marketing team communications.

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)? This program is now available at all locations but forsee new staff trainings. Cost is lowered by ordering directly from vendor for the cuffs. The cuff is not on the validated BP list and the organization is considering switching to a new cuff brand to be in line with other standards.