Western Wayne Intervention Assessment

Internal Characteristics

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

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.

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

What are the infrastructure characteristics of your health center (use of the expanded

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 development of a treatment protocol for hypertensive patients and pilot implementation of the protocol.

Chosen Intervention: EMBED ALGORITHM INTO CARE PROCESSES.

Date when implemented: October, 2023

Updates: 1/18 - to implement algorithm into care processes followed by pilot-providers.

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

Reach of implementers/providers?

Planned: 12 Providers

1. Taylor IM - 3 Providers

2. Lincoln Park IM - 3 Providers

3. Inkster IM - 5 Providers

4. Dearborn IM - 1 Provider

Reach of implementers/providers?

Data Update: (2/27/2024)

1. Taylor IM - 3 providers

2. Lincoln Park IM - 3 Providers

3. Inkster IM - 5 Providers

4. Dearborn IM - 1 Provider

Actual:

Taylor and Inkster sites are implementing interventions to pilot the algorithm.

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

1. 5% of patients from HTN no therapy to guideline therapy.

Goal: 24 patients with uncontrolled HTN on no therapy to monotherapy or combination therapy.

2. 5% patients from HTN on monotherapy to guideline recommended therapy.

Goal: 26 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 - 16.33%

• # AA pts. w/uncontrolled HTN on monotherapy: 141/502 - 20.08%

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

Actual:

Data Update: (2/27/2024)

• # AA pts. w/uncontrolled HTN on no therapy: 63/497 - 12.67% | We had a 3.66% decrease in this measure, showing a positive trend. That is about 18 patients who are now receiving mono/combination therapy since our baseline date: (6/30/2023).

• # AA pts. w/uncontrolled HTN on monotherapy: 127/497 - 25.55% | We had a 5.47% increase in this measure, showing a positive trend. That is about 28 patients who are now receiving mono-therapy since our baseline date: (06/30/2023).

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.

NOTE: NACHC glad to assist with survey methodology

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

Currently monitoring Uncontrolled HTN on No Anti-HTN Medications and AMA MAP BP™ - HTN-Medication Intensification scorecards.

Monitor Excel sheets with patient gaps - check charts to see if visits are fulfilled.

Refection of data unto the Azara scorecards on a monthly basis. Shared data at provider meetings (Dr. Malcolm and NP Gertz) for updates.

What outcomes do you expect?

Standardized protocol for all Providers throughout Western Wayne.

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

Improvement on AMA MAP BP™ - HTN-Medication Intensification increased by 15%. Goal: 30%.

What outcomes have you seen?

For HTN Medication Intensification, we have been able to move our percentage rate from 1% from 15% - 16% for AMA MAP BP™ - HTN-Medication Intensification for WWFHC. Date: (02/27/2027)

We have been able to move our percentage rate from a 1% decrease from 13% - 12% for Uncontrolled HTN on No Anti-HTN Medications for WWFHC (inverse measure). Date: (02/27/2027)

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?

We have been able to reach our target population as a result of point-of-contact through PVP Azara cohort alerts.

What unintended consequences or outcomes might there be?

1. Provider apprehension

What unintended outcomes did you experience?

We are moving slower pace due to patient availability for scheduled appointments. Provider schedules are at times booked beyond a one-month period.

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?

Introduction of algorithm took place in a provider meeting where all providers were present.

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?

1/4 (25% of our providers) are implementing this intervention through WWFHC.

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?

Meetings were arranged prioritizing change management, now we are moving back to project implementation. Currently have provider buy-in.

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: Presenting Million Hearts metrics quarterly at our Inter Quality Improvement Committee (IQIC) meetings to our clinical staff.

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: Million Hearts progress metrics presented during our X Date IQIC meeting and were well received by our clinical team.

How will you spread your intervention and lessons learned?

We will share updates on the progress of Million Hearts metrics quarterly at our 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)?

Need to have a standardized and continuous system of patient outreach. Perhaps investing in a tech solution that automates this.

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: INCREASE TOUCHPOINTS

Date when implemented: October, 2023

Updates: Established increase touchpoints across our Medical Assistants, Community Health Workers, and Providers to scheduled within a 2-4 week range by point-of-contact.

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

Reach of implementers/providers?

Planned: Inform clinical staff from each site of our new workflow establishing HTN follow-up appointments within a 2-4 week period.

Clinical Staff Include: Doctors, Nurse Practitioners, Nurses, Community Health Workers, Clinical Supervisors.

Reach of implementers/providers?

Actual:

Established 2-week follow up workflow with our CMO, Dr. Malcom.

Held a meeting with our Clinical staff at each site to review and solicit feedback on the established workflow for follow-up visits within 2-4 weeks of initial HTN visit.

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

1. 50% of patients to receive follow-up visits within 2-4 week period.

Goal: 242 Patients in need of HTN follow-up visits scheduled within 2-4 weeks of initial high BP visit.

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

• # AA pts. Follow-Up After Visit w/uncontrolled HTN: 191/866 - 22.05%

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

Actual:

Data Update: (2/27/2024)

• # AA pts. Follow-Up After Visit w/uncontrolled HTN: 209/883 - 23.66% | We had a 1.61% increase in this measure, showing a positive trend. That is about 14 patients who had HTN follow-up visit scheduled within 2-4 weeks since our baseline date: (6/30/2023).

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working?

Monitor data in the AMA MAP BP™ - HTN-Follow-Up After Visit with Uncontrolled HTN in Azara on a monthly basis.

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

We’ve been able to monitor data by site through the AMA MAP BP™ - HTN-Follow-Up After Visit with Uncontrolled HTN scorecard in Azara.

What outcomes do you expect?

Improvement in overall HTN follow-up measure coinciding with the HTN Medication Intensification measure.

What outcomes have you seen?

Improvement in our AMA MAP BP™ - HTN-Follow-Up After Visit with Uncontrolled HTN scorecard in Azara.

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?

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

2. Lack of buy-in from providers and our clinical staff

3. Slow implementation

What were the barriers to consistent intervention implementation?

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

Automatic scheduling capabilities would be helpful for 2 week follow-up measure.

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: IQIC data provided to clinical staff and at provider meetings.

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: IQIC data provided to clinical staff and at provider meetings.

How will you spread your intervention and lessons learned?

Need to have a standardized and continuous system of patient outreach. Perhaps investing in a tech solution that automates this.

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)?