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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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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 | |
)? | Hamilton Community Health Network (HCHN) is a FQHC in the Flint MI and surrounding areas with 8 mostly urban sites and 1 small rural site. |
What are the infrastructure characteristics of your health center (use of the expanded care team, culture)? |
How do interventions and/or workflows need to be adapted to ensure health equity? | SDOH are assessed and barriers addressed for all new patients, annually and when life situations change by protocol at HCHN. Staff must ensure these screening assessments are completed on all patients and all interventions related to SDOH addressed to ensure health equity. |
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)? | Current lack of and transition of staffing will be our most difficult struggle to implementation. Training staff may be disruptive at initiation and training must fit clinic schedule of training times. |
What are key characteristics of the participating setting(s)? | Established in 1983, Hamilton is the largest FQHC in Genesee County with seven clinics and one clinic in Lapeer County. We have over 200 employees and a network of over 40 providers specializing in primary care/family medicine, pediatrics, obstetrics/gynecology, optometry, oral health, podiatry, behavioral health and psychiatry. Additionally, Hamilton has Michigan Medicine (University of Michigan) physicians and providers attend specialty clinics monthly. Those clinics include urology, gynecology, and breast health. |
External Characteristics | |
What external or environmental supports or threats are there? | Hamilton is located in a food desert and transportation tends to be a barrier due to patients feeling unsafe on public transportation. |
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 not on guideline recommended therapy and/or on monotherapy Plan for intervention: Use Azara to identify and cohort patients with uncontrolled HTN and not on guideline therapy or monotherapy to show on patient visit planning report for morning huddle discussion. | Chosen Intervention: Patients with uncontrolled hypertension not on guideline recommended therapy and/or on monotherapy Date when implemented: Second quarter 2024 Updates: Train new staff and retrain current staff on Azara PVP and cohort management. Training to be schedule with MPCA Staff. PVP in the morning, training is needed for the MA, nurses, then the providers Process will start with huddles the day before with MA and nurses |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 100% of medical site staff will implement the use of PVP and huddle and discuss uncontrolled HTN not on guideline therapy or monotherapy. | Reach of implementers/providers? 35 PCPs trained to discuss monotherapy or guideline therapy, 8 nurses to be trained to implement use of PVP Actual: Training was completed for 35 PCPs in December 2023. |
Reach of patients (# of patients receiving treatment intensification)? Patient goal- On no therapy- 8 patients On Monotherapy- 21 patients Planned:
| Reach of patients (# of patients receiving treatment intensification)? Actual:
(Increase in number of patients on no therapy and on monotherapy is due to a transition in EMR and addition of historical data.) |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? Monitor Azara DRVS for decrease of pts not on guideline therapy and/or monotherapy. | Were you able to accurately measure how your intervention was working? Now that there is a full data set of patients (current and historical) available, going forward we will increase our accuracy of measuring this work. |
What outcomes do you expect? Decrease in 10% of patients with no guideline therapy and/or monotherapy. | What outcomes have you seen? Decrease patients on no therapy by 41 and patients on monotherapy by 145, exceeding our goal of 10%. |
How will you ensure your intervention will be effective for your target population? Add this metric to monthly provider site meetings with interventions and expected outcomes. | Did your intervention reach the target population? Yes |
What unintended consequences or outcomes might there be? No movement in metric | What unintended outcomes did you experience? We are now re-evaluating who to engage in the workforce to sustain this intervention. |
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. Quality Team introduces the planned implementations during the monthly provider meetings and show metric and movement on measure. Care teams including staff nurses and medical assistants would be the ones pulling PVP and conduct morning huddles. | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? Quality Team delivered their component of the intervention. Plan skills available for intervention. Moving forward, more time and resources are needed to complete this intervention. |
How will you know if clinicians/care teams/sites used the intervention? Decrease in the percent of patients in DRVS on monotherapy and an increase of those on guideline therapy. | What proportion of the planned staff/sites implemented the intervention? 35 Providers received intervention training. (100%) 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.)? Staff at smaller sites had more success in adopting the intervention. |
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? This intervention is an agenda item on each provider monthly meeting and discussion of barriers and successes are addressed. | How did you track modifications during the intervention? Meeting minutes, chat roll-call in Zoom, Zoom recording |
What might be some of the possible obstacles to consistent implementation? Lack of consistent staffing, Provider apprehensive in changing prescribing practices, lack of provider engagement | What were the barriers to consistent intervention implementation? Challenge recruiting and retaining consistent staff, Provider apprehensive in changing prescribing practices, lack of education regarding entering second BP measurement, lack of Provider engagement |
What costs and resources (including time and burden, not just money) need to be considered? Staff do not engage in huddle or use PVP to identify and discuss patients to intervene and use interventions. Quality team members available to monitor interventions and pharmacy staff engagement into HTN control interventions. | What costs and resources (including time and burden, not just money) need to be considered? Challenge recruiting and retaining consistent staff, time spent retraining new staff (onboarding as well as specific roles) Posters will be used in rooms |
How closely did the staff/sites follow the intervention design and deliver as intended? Foundation laid for huddle exercise. Training was delivered but due to staff turnover, retraining is needed. 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: Reinforcements will include HTN protocols, PVP alerts, training and regular reporting. | What reinforcements did you put into place to sustain the intervention?
Explain: |
How will you spread your intervention and lessons learned? Use monthly site meetings to spread interventions, barriers to implementations and successes. | How will you spread your intervention and lessons learned? Staff meetings, face to face, read and sign, audit tool, MPCA education Protocols are created for PVP in the morning and educating MA, Nurses, patient educators |
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 focus on retention of staff across the organization, 30/60/90 day check-ins with staff. Medical assistant in-house training and recruitment from MA programs. Providing access to training virtually. | |
Intervention #2 Plan | Intervention #2 Actual |
Describe Intervention (Select ONE; useBPAA Project Roadmap for ideas on evidence-based strategies) Chosen intervention: Expand care team encounters to include medication education and adherence coaching Plan for intervention: Use PVP tool to identify uncontrolled HTN cohort and use soft handoff or referral for Health Educators to join care teams to preform medication education and adherence coaching. | Chosen Intervention: Expand care team encounters to include medication education and adherence coaching Use PVP tool to identify uncontrolled HTN cohort and use soft handoff or referral for Health Educators to join care teams to preform medication education and adherence coaching. Date when implemented: September 2023 Updates: Trainings happened in September and December 2023. Peer reviews occurred in February 2024. |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 100% site care teams introduced to expansion of care team intervention. | Reach of implementers/providers? Actual: |
Reach of patients (# of patients receiving treatment intensification)? 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? Percentage of patients with uncontrolled hypertension will decrease and track referrals to health educators for hypertension therapy. | Were you able to accurately measure how your intervention was working? |
What outcomes do you expect? 10% improvement on BP control of the HCHN HTN cohort | What outcomes have you seen? |
How will you ensure your intervention will be effective for your target population? Controlling BP measure will increase for AA cohort. | Did your intervention reach the target population? |
What unintended consequences or outcomes might there be? Providers and care teams do not engage in education opportunity by utilizing the health educator or CHW to address barriers. | 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. Quality Team introduces the planned implementations during the monthly provider meetings and show metric and movement on measure. Quality Director will introduce intervention during HE team meetings. Care teams will refer appropriate patients to the health educators who will conduct the education with the patients. | 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? Referrals to HE for HTN control will increase. | 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? HTN control will improve and number of referrals to HE for HTN education will increase. | How did you track modifications during the intervention? |
What might be some of the possible obstacles to consistent implementation? Non-engagement of care teams | What were the barriers to consistent intervention implementation? |
What costs and resources (including time and burden, not just money) need to be considered? Staffing struggles to continue implementation and stay focused on implementation | 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: Reinforcements will include HTN protocols, PVP alerts, training and regular reporting. | What reinforcements did you put into place to sustain the intervention?
Explain: |
How will you spread your intervention and lessons learned? Use monthly site meetings to spread interventions, barriers to implementations and successes. | 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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