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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, use of expanded care team, culture)? | Urban, refugee/immigrant population, non-English speaking |
How do interventions and/or workflows need to be adapted to ensure health equity? | WYH is focusing on all patient populations with HTN |
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)? | Goal is to meet patient where they are at. |
What are key characteristics of the participating setting(s)? | clinic, face to face, phone |
External Characteristics :SDOH barriers, affording medication, limited insurance coverage, non covered transportation | |
What external or environmental supports or threats are there? | Supports: Unite Us Referral Platform to meet SDOH needs, not being able to meet patient needs due to a lack of insurance coverage and patient lacks funds. |
Treatment Intensification (Combination Therapy) Plan | Treatment Intensification (Combination Therapy) Actual |
Describe Intervention: Real time identifying patients that meet We have changed our BP criteria to 130/80>. Criteria for program. Nurse refers patient in clinic . with BP 130/80 or >.to Million Hearts program (Select ONE; useBPAA Project Roadmap for ideas on evidence-based strategies) Chosen intervention: Med adhearenceadherence, pt. engagement. Plan for intervention: nurse Nurse refers pt. to traige triage nurse who meets with pt. Triage nurse will refer to clinical pharm. | Chosen Intervention: Date when implemented: Updates: |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Clinical Pharm. Working Pharmacist working with providers to educate best practice related to evidence based guideline. Planned: Provider education/recommendations for med tx - have identified in data that there is an opportunity to improve statins and ACEs/ARBSs appropriate use . Clinical pharmacist will provide education at provider meeting on statin initiation and ACEs/ARBS | Reach of implementers/providers? Actual: |
Reach of patients (# of patients receiving treatment intensification)? Prescribed : 66%, 223/340 African American BP control 63%, 612/971. F/U appt scheduled with clinical pharmacist and provider. 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? Goal: improved medication ordering data for pt newly dx with HTN | Were you able to accurately measure how your intervention was working? |
What outcomes do you expect? Goal: improved medication ordering data for patient newly dx. with HTN | What outcomes have you seen? |
How will you ensure your intervention will be effective for your target population? Team meets every 2 weeks to discuss referrals patient engagement, barriers and options to overcome barriers. We measure based on the data collected when we meet. Evaluate what is working and what is not. | Did your intervention reach the target population? |
What unintended consequences or outcomes might there be? Providers not fully engaged with evidence base treatment recommendations. patients lack of engagement. | 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. Triage Nurse, Care Managment, clinical pharmacist. All clinic locations. Nursing staff has been educated to send referrals via Athena and verbally, in real-time as patient is seen in clinic with HTN to Triage Nurse who will see patient or reach out to them via phone in real-time. Clinical Pharmacist can also see patient if Triage Nurse is not available. | 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? Data collection. We are monitoring second BP reads and how many of those patients are referred to Triage Nurse to start patient education and engage patient to Million Hearts Program. | 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 data and recording every two-week team meetings. | How did you track modifications during the intervention? |
What might be some of the possible obstacles to consistent implementation? The pace of the clinic, other real-time identified needs. | What were the barriers to consistent intervention implementation? |
What costs and resources (including time and burden, not just money) need to be considered? Enough staff to carry out the work. | 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? The data is monitored every two weeks when we have our check in meeting to evaluate our progress/barriers etc. Two education sessions has been delivered to nursing staff regarding taking second BP and referring HTN patients to Triage Nurse to follow with patient. | 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? Data is the driver to effective outcomes. We will continue to meet every two weeks as a check in to evaluate workflow barriers or need for change to workflow and or staff education needs.
Explain: We are working with marketing team to create patient awareness with a banner for clinic asking patients if they know their numbers Staff will also wear a button type pin on uniform with same message. | What reinforcements did you put into place to sustain the intervention?
Explain: |
How will you spread your intervention and lessons learned? Education / Updates to project sharing data with providers and staff. | 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)? | |
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