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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, use of expanded care team, culture)? | Unity Health Care is the largest community health center providing over 400,000 visits annually in an urban setting. We provide care to 1 in 8 residents of Washington DC. The majority of the patients are African-American and the majority of patients are covered under DC MCOs. Approximately half of all adult patients have a diagnosis of hypertension. Half of all patients with hypertension have blood pressure readings greater than 140/90 at their last visit. |
What are the infrastructure characteristics of your health center (use of expanded care team, culture)? | |
How do interventions and/or workflows need to be adapted to ensure health equity? | Organizational adopted guideline treatment with particular emphasis based on race to ensure evidence guided treatment to reduce health disparities |
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)? | The complexity of the intervention is moderate based particularly in limited staffing with dedicated time to work on program, ease of accessing data, data reporting, and time to develop the program. |
What are key characteristics of the participating setting(s)? | Largest FQHC in Washington DC, large patient panel, majority of patients have some form of health coverage, and health care centers located in all wards of DC. |
External Characteristics | |
What external or environmental supports or threats are there?
| Supports: MCO coverage of many HTN medications, BP monitors covered by MCOs, and availability of health related organizations in DC. Threats: Barriers to access to care, access to healthy food and safe spaces, and financial constraints of patients and health related organizations in DC. |
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: hypertension self-management program (determining # of visits over period of time, similar to diabetes SMP - 2 hours sessions not sustainable here). Target population TBD- outreach probably based on patients with uncontrolled BP >150 or self-selected; or using patients in provider visit referred to program. Hypertension self-management program to educate patients with a diagnosis of hypertension how to manage blood pressure and improve health habits. Target population is patients with uncontrolled hypertension on no therapy, on monotherapy, out of care >1 year, and all others interested in attending. The intervention will consist of weekly interactive group sessions to educate patients about the disease process and active interventions the patients can engage in to improve blood pressure and thus reduce cardiovascular risk. Plan for intervention: Recruitment: Patients will be recruited using various methods including outreach, posters, provider and nurse referrals, and monitors in waiting area. Aim for 8 or more participants per session. Intervention: Enrolled patients will attend weekly standardized sessions to cover topics including understanding hypertension, medications, diet and physical activity. NP Residents will be divided into groups and will hold group visits at various times and days of the week. Evaluation: Objective measures will include adherence with prescribing following guideline recommended therapy, blood pressure readings <140/90, patients’ compliance with medications, weight change, ASCVD risk, checking BP at home. Subjective measures will include patients’ perceptions of health and barriers to blood pressure control. | Chosen Intervention: Development of HTN self management program include a 4 session curriculum and workbook Date when implemented: Updates: 12/21 - develop standardized curriculum for group or nurse visits lack of understanding - framework of diabetes self-management want to model htn off this. want to standardize so all patients receive this information - group visits hopefully Mary suggestion: might be more of a standing order than curriculum - choosing what is most relevant to patient (med adherence, salt reduction, smoking cessation, SMBP, etc.) nurse will do needs assessment and see patient to address what comes up from needs assessment which medication do you want to add question to provider billing for 1 on 1 vs group visits nurse sets strict boundaries - provider will come in her for x and schedule follow up visit once create standing order can create order set - standardize orders (lab, education, NRT) Update 4/2024: Curriculum still being developed. Unity is meeting with consultant that will help get the curriculum finalized. |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: All Clinic Staff at site: Number of providers at East of the River=10, nurses=2, MAs=10 | Reach of implementers/providers? Planned # providers=10 Actual: Considering 4 for the NP residency |
Reach of patients (# of patients receiving treatment intensification)? Planned:
| Reach of patients (# of patients receiving treatment intensification)? Actual: TBA based on the number of patients empaneled to the NP residents |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? Attendance at these visits and BP readings. | Were you able to accurately measure how your intervention was working? TBA |
What outcomes do you expect? For patients to have a better understanding of HTN, for them to know how to live healthy lives with HTN, and how to properly measure their BP at home. Will utilize pre- and post-test for knowledge gain. | What outcomes have you seen? TBA |
How will you ensure your intervention will be effective for your target population? Unity will utilize pre- and post- test for knowledge gain of patients around their HTN. | Did your intervention reach the target population? TBA |
What unintended consequences or outcomes might there be? | What unintended outcomes did you experience? Development of the curriculum is taking longer than anticipated. Staff is at capacity, so Unity will now utilize contractor to get the curriculum done. Meeting with the contractor will take place mid-April. |
Adoption (#/% and representativeness of staff and sites who implemented the intervention) How did clinicians respond to | |
inter ventions to intensify medication more rapidly/address therapeutic inertia? | |
Adoption answer: Weekly group visits will ensure increased access and timely adjustment of treatments. Also exploring having a control group for patients to return to clinic weekly for medication adjustment without the group educational sessions. Who will deliver the intervention (actually do the work)? Include staff and sites, if applicable. NP Residents at EOR. | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? Considering RNs and NP Residents --RNs and NPs have the skills and will be trained how to implement the HTN self-management program --RNS and NP residents might not have the time to implement the program |
How will you know if clinicians/care teams/sites used the intervention?Monitor attendance of group visits and utilizing pre-and post-tests. | What proportion of the planned staff/sites implemented the intervention? TBA 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.)? TBA |
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 Lead will meet weekly with NP Residents to debrief how the group visits worked. | How did you track modifications during the intervention?NP Residents will be given time for QI projects and will be debriefed on the implementation of the self management program. |
What might be some of the possible obstacles to consistent implementation? There could be an issue around referrals (we have seen this with the DSMSES Program) and patients actually attending the sessions once they have signed up. Knowledge of sessions/training and participant attrition also looked at as possible obstacles. | What were the barriers to consistent intervention implementation? TBA |
What costs and resources (including time and burden, not just money) need to be considered?Clinical support, organizational commitment, facility space to hold sessions, loss of revenue if poor attendance, financial and time costs for marketing program, logistical and administrative time to manage outreach and data, ability to access data reports. | What costs and resources (including time and burden, not just money) need to be considered? --Time: group visits 1-2 hours per session, time needed to contact patients and remind them of sessions --Financial: cost of printed materials, cost of incentives for patients, loss of revenue due to no shows --Resources: conflict of nurse involvement in self management program vs their other duties |
How closely did the staff/sites follow the intervention design and deliver as intended? Check all that apply:
Modifications made and other notes: TBA | |
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: Unity will utilize routine reports and trainings to be sure that the intervention continues to be effective. Reporting will be used to adjust the intervention where it is seen fit. Unity will also continue to train staff on the curriculum of the program and make any updates as policies change. | What reinforcements did you put into place to sustain the intervention?
Explain: TBA |
How will you spread your intervention and lessons learned? Utilizing the HTN and Chronic Care Working Group meetings and Unity wide communications. | How will you spread your intervention and lessons learned? Utilizing the HTN and Chronic Care Working Group meetings, staff meetings, and Unity wide communications. |
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)? Will need recurrent trainings | |
Intervention #2 Plan | Intervention #2 Actual |
Describe Intervention (Select ONE; useBPAA Project Roadmap for ideas on evidence-based strategies) Chosen intervention: Outreach intervention to engage patients with uncontrolled blood pressure readings using text messaging system Luma to schedule with PCP for blood pressure management and sign up for HTN SMBP program. Plan for intervention: Unity utilized data from the Azara system to identify patients who have a BP greater than 140/90. Unity will use LUMA to send patients a link to opt in for SMBP education. | Chosen Intervention: 2/15: Date when implemented: messaging sent in November or December (will need to circle back on this) Updates: 2/15: text message survey do you want to get back into care. survey went into spreadsheet divided by health center and went to nurse managers Updates: none -(4/2024) |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: All clinical staff | Reach of implementers/providers? Actual: Approx 150 providers |
Reach of patients (# of patients receiving treatment intensification)? Planned: 10,000+ messages sent out to patients with BP>140/90.
| Reach of patients (# of patients receiving treatment intensification)? Actual: 9,999 |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? Unity will use the number of patients that choose to “opt-in” to determine if the intervention is working or not. | Were you able to accurately measure how your intervention was working? 2/15: message that got in for visit - this intervention created before nurse visits are not billable anymore, also have shortage of nurses and they are being redistributed, who from team can pitch in 4/2024: Yes. We were able to see how many patients received the text message |
What outcomes do you expect? Unity expects patients to receive the message and either opt-in to receive care or choose not to opt-in. Unity feels this will lead to a decrease in patients who have a BP>140/90. | What outcomes have you seen? have found out that people will respond to these text messages 500 responded of the 10,000 sent out Updates: 4/2024: Approx 5% of patients responded to the text message |
How will you ensure your intervention will be effective for your target population? Unity will measure number of patients who schedule a follow up appt with PCP. | Did your intervention reach the target population? Yes |
What unintended consequences or outcomes might there be? There could be a low response rate to the text messages being sent out, patients could disengage, and patients could view message as spam. | What unintended outcomes did you experience? Limited ability of nurses to schedule appointments for patients with either a provider or for nurse visits. Limited time for nurses to reach out to patients to discuss HTN and to schedule appointments. |
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. Unity’s Chief Medical Information Officer, Chronic Care Program Manager, and Nurses. | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? --Luma message sent by grants and programs department. Yes, they were able to complete the sending of the message --Nurses have the skill to do outreach but don’t have the time |
How will you know if clinicians/care teams/sites used the intervention? Unity will need a workflow to ensure there is a nurse visit order. The team is looking into developing a HTN template in eCW. | What proportion of the planned staff/sites implemented the intervention? --Grants/Programs Department= 100% --Outreach by nurses = 0% 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.)? No |
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? All modifications will have to be presented to the Chronic Care Program Manager and HTN Lead. | How did you track modifications during the intervention? Discussion during HTN QI Workgroup meetings |
What might be some of the possible obstacles to consistent implementation? Lack in responses from patients and patients, the nurse visits getting scheduled (capacity issues in clinics), and patients actually attending the visits. | What were the barriers to consistent intervention implementation? Time constraints of the nurses |
What costs and resources (including time and burden, not just money) need to be considered? Clinical support, organizational commitment, facility space to hold sessions, loss of revenue if poor attendance, financial and time costs for marketing program, logistical and administrative time to manage outreach and data, ability to access data reports. | What costs and resources (including time and burden, not just money) need to be considered? --Time: amount of time to call each patient to schedule a nurse visit --Resources: no standing orders for nurse visits, nurses have to solicit orders from providers to schedule nurse visits |
How closely did the staff/sites follow the intervention design and deliver as intended? Check all that apply:
Modifications made and other notes: Need to remind nurses to reach out to patients to schedule patients with uncontrolled HTN | |
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: Regular reporting and following up with clinical staffing. | What reinforcements did you put into place to sustain the intervention?
Explain: Regular trainings and reminders to reach out to patients will be needed as priorities shift over time. Need to incorporate outreach into daily practice. |
How will you spread your intervention and lessons learned? Utilizing the HTN and Chronic Care Working Group meetings and Unity wide communications. | How will you spread your intervention and lessons learned? Will send updates through Communications and with the annual Heart of Gold competition to recognize outstanding health centers within Unity exceeding HTN goals. |
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)? --Consider monthly Luma messages to engage patients in wellness and HTN improvements --Reminders to reach out to patients with uncontrolled HTN --Regular trainings --Communications for tips and tricks to improving BP control --Consider PRC to call patients and schedule nurse visits | |
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