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Treatment Intensification (Combination Therapy) Plan | Treatment Intensification (Combination Therapy) Actual |
Describe Intervention (Select ONE; useBPAA Project Roadmap for ideas on evidence-based strategies) Chosen intervention:
Patients with uncontrolled hypertension Patients with uncontrolled hypertension: Not on a guideline-recommended therapy On mono-therapy Patients with undiagnosed hypertension
Utilize our new population health software, Azara, to create/disseminate a health registry, or tracking type, which will be accessible at point of care for clinical decision making. Design new Million Hearts care gap dashboard and reports to address therapeutic inertia and control rates. Continue to train clinicians on guideline-supported treatment algorithm (AMA Hypertension Treatment algorithm). Continue SMBP program to support clinical decision making to address inertia and intensification. | Chosen Intervention: Develop population health registries and point of care clinical decision support Date when implemented: January 1, 2024 Updates: The process to transfer to connect and migrate our historical and current EMR Data into Azara began in October 2023 |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: Intervention to be implemented across the organization. | Reach of implementers/providers? Actual: TBD upon implementation |
Reach of patients (# of patients receiving treatment intensification)? Planned: All uncontrolled hypertensive patients - approximately 500 AA Uncontrolled HTN patients will be part of registry*. (*AA Pts with last BP >140/90 during the reporting period-as of 6/30/23: 537)
| 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? Azara Dashboard and Analytic Report designed for chosen MH Intervention | Were you able to accurately measure how your intervention was working? |
What outcomes do you expect? A 10% increase in HTN Control with AA patients. A 20% decrease in # AA pts w/ uncontrolled HTN on Monotherapy A 10% decrease in # AA pts w/ uncontrolled HTN on Monotherapy and No Therapy | What outcomes have you seen? |
How will you ensure your intervention will be effective for your target population? Utilize a PDSA to review the workflow designed to best utilize the population health registries and point of care clinical decision support to identify AA pts w/ uncontrolled on Monotherapy or No Therapy. | Did your intervention reach the target population? |
What unintended consequences or outcomes might there be? Patients may not tolerate a specific combination of HTN medications as part of intensification, pt, or providers may have future reluctance to use a second agent. | 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. Clinical Care Team and Office Manager at each site; Performance Improvement Coordinator, Program Coordinator and Patient Engagement Specialist. | 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? Dashboard, reports and chart reviews performed per PDSA | 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? Tracking and reviewing the intervention PDSA | How did you track modifications during the intervention? |
What might be some of the possible obstacles to consistent implementation? Dissemination and adoption of the registry at the point of care. Provider reluctance to intensify treatment, patient reluctance to intensify due to fear of side effects. | What were the barriers to consistent intervention implementation? |
What costs and resources (including time and burden, not just money) need to be considered? SMBP cuffs are an integral part of our approach but are a limited resourcesresource, how do we sustain access do these cuffs? | 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: If intervention demonstrates a positive outcome we will reinforce by continuing our iterative PDSA cycle, documenting policies/protocols, and include in our Quality Improvement plan approved annually by our board.. | What reinforcements did you put into place to sustain the intervention?
Explain: |
How will you spread your intervention and lessons learned? Through our MH network, Organizational QI mtgs and monthly staff 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: Improve Medication Adherence Plan | Intervention #2: Improve Medication Adherence Actual |
Describe Intervention (Select ONE; useBPAA Project Roadmap for ideas on evidence-based strategies) Chosen intervention: Assess for non-adherence (e.g., questionnaires, pill counts, contextual flags, missed appointments, infrequent refills) Medication Therapy Management: Expand care team encounters to include medication education and adherence coaching (Elective Strategy) … via in-person or telehealth consultations with Rite Choice pharmacypharmacist. Assess for non-adherence (e.g., questionnaires, pill counts, contextual flags, missed appointments, infrequent refills) Offer solutions: Prescribe low-cost generics. Prescribe single-pill combination therapy. Align prescription refills. Approaches to address “forgetfulness” | Chosen Intervention: Chosen intervention: Assess for non-adherence (e.g., questionnaires, pill counts, contextual flags, missed appointments, infrequent refills) Medication Therapy Management: Expand care team encounters to include medication education and adherence coaching (Elective Strategy) via in-person or telehealth consultations with Rite Choice pharmacist. Date when implemented: 1/1/2024 Updates: Intervention concept to be presented to Internal Medicine and CRNP providers for discussion and approval before moving forward. |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: Intervention to be implemented with patient patients of Internal Medicine and CRNP providers at our Eastside site where a Rite Choice Pharmacy is located. | Reach of implementers/providers? Actual: |
Reach of patients (# of patients receiving medication adherence)? Planned: A Medication Therapy Management (MTM) cohort of 15 - 20 of AA pts w/ uncontrolled HTN | 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? Track control rates, medication adherence and continuity of care with MTM cohort. may also track refills but this does not = to medication adherence | Were you able to accurately measure how your intervention was working? |
What outcomes do you expect? A 75% control rate for AA Pts w/ uncontrolled HTN chosen for MTM cohort. | What outcomes have you seen? |
How will you ensure your intervention will be effective for your target population? Cohort will be identified utilizing the Population Health Registry and provider referral of patient patients who would best benefit. Effectiveness will be best insured by utilizing a PDSA to review the worflow workflow which will be designed to best utilize the MTM intervention. | Did your intervention reach the target population? |
What unintended consequences or outcomes might there be? Providers become resistant to the intervention due to due to patient reluctance, or intervention roll-out delays/issues. | 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. Internal Medicine providers, CRNP, Rite Aid Pharmacy, Office Manager at the Eastside site; Performance Improvement Coordinator, Program Coordinator and Patient Engagement Specialist. | 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? Dashboard, reports and chart reviews performed per PDSA | 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? Tracking and reviewing the intervention PDSA. | How did you track modifications during the intervention? |
What might be some of the possible obstacles to consistent implementation? PT comfort level with the MTM virtual, or in-person visits. PT keeping scheduled visits, adherence to guidance. How does do we most efficiently communicate medication change with providers, if this is unclear or inconsistent it could be problematic. | What were the barriers to consistent intervention implementation? |
What costs and resources (including time and burden, not just money) need to be considered? The MTM visit is not reimbursable, is Rite Choice in a position to continue pilot if successful. | 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: If the reports, dashboards and chart reviews demonstrate a positive outcome reinforcing we will reinforce this program by creating desiciion decision support trigger triggers in our EMR, MTM protocols, and training/mtgs b/t providers and pharmacists. | What reinforcements did you put into place to sustain the intervention?
Explain: |
How will you spread your intervention and lessons learned? Through our MH network, Organizational QI mtgs and monthly staff 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)? : Investigate options for MCO reimbursement. | |
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