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Instructions: Use the pencil icon in the top right to edit the form below. ↗️ Remember to push PUBLISH when you are done to save your work. |
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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 develop 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: 18 Providers | Reach of implementers/providers? Data Update: (2.27.24 Site update/27/2024)
Actual: Taylor and Inkster sites are implementing interventions to pilot algorithm. |
Reach of patients (# of patients receiving treatment intensification)?
Goal: 24 patients with uncontrolled HTN on no therapy to monotherapy or combination therapy.
Goal: 26 Patients with uncontrolled HTN on monotherapy to combination therapy. Baseline Data (as of 6/30/2023):
| Reach of patients (# of patients receiving treatment intensification)? Actual: Data Update: (2/27/2024)
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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 WayneWayne. 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?
| 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 prioritizing change management, now are moving back to project implementation. do 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:
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: IQIC data provided to clinical staff and at provider meetings. | What reinforcements did you put into place to sustain the intervention?
Explain: IQIC data provided to clinical staff and at provider meetings. |
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)? | |
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: Increase follow-up appointments by 50% in patients who have uncontrolled HTN. Reach of implementers/providers? Actual: We have increased Inform all medical staff from each site of establishing HTN follow-up appointments within a 2-4 week period. Medical Staff: Doctors, Nurse Practitioners, Nurses, Community Health Workers, Clinical Supervisors. | Reach of implementers/providers? Actual: Medical staff at each site throughout Internal Medicine notified to establish follow-up visit methods within 2-4 weeks of initial HTN visit. |
Reach of patients (# of patients receiving treatment intensification)?
Goal: 96 50 Patients with HTN follow-up visits. Baseline Data (as of 6/30/2023):
| Reach of patients (# of patients receiving treatment intensification)? Actual: Data Update: (2/27/2024)
Reach of patients (# of patients receiving treatment intensification)? Actual:
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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 on Uncontrolled HTN on No Anti-HTN Medications reduced by 5%. Goal: 10%in overall HTN follow-up measure coinciding with the HTN Medication Intensification measure. | What outcomes have you seen? Improvement on Uncontrolled HTN on No Anti-HTN Medications from 10/2023 - Presentin 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? |
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:
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: IQIC data provided to clinical staff and at provider meetings. | What reinforcements did you put into place to sustain the intervention?
Explain: IQIC data provided to clinical staff and at provider meetings. |
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)? | |
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