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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: Having a provider champion train clinicians on guideline-supported treatment algorithms Plan for intervention: Provider champion (Dr. Vanessa Grubbs) will help train and educate new providers on treatment algorithms to speed up the onboarding process and will refresh knowledge sharing efforts for existing provider group; the plan is to have her help new clinicians become aware of existing workflows and get them quickly up to speed; she will essentially be in communication with providers to help bridge the information gap; cadence and structure of training will be determined, but she will begin joining internal meetings to discuss HTN workflows and any needed workflows changes | Chosen Intervention: provider champion for clinician training on guideline-supported treatment algorithms Date when implemented: August 2023 Updates: 12/20/24 - meeting tomorrow for updates still trying to communicate with new clinicians, CHCN will be getting facetime to see how this works right now mono is still first - trying to move this to SPCT | ||
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |||
Reach of implementers/providers? Planned: 9 providers (includes provider champion) Reach of implementers/providers? Actual:2/26/24 - workflow has been updated; NP Kim will be clinician champion mostly seeing patients who are disconnected from care to review status of HTN treatment, medication, and overall health; health coach will then provide after visit education which includes information on how to improve BP, log medication, prep for appointments, and resources for SDOH-related needs that have been identified - this is a “tag team” approach between clinician and Community Health Advocate team Provider champion still TBD | |||
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |||
Reach of implementers/providers? Planned: 9 providers (includes provider champion) | Reach of implementers/providers? Actual: 1 provider (NP Kim), 1 RN (Anekaila Crevani), 1 CHA, 1 health coach/educator (Liviier Lara) | ||
Reach of patients (# of patients receiving treatment intensification)? Planned: 70/556 (no therapy) and 164/556 (monotherapy)
| Reach of patients (# of patients receiving treatment intensification)? Actual: TBD - Liviier started education portion but full launch with NP Kim appts predicted for March | ||
Efficacy (Impact of intervention on important outcomes) | |||
How will you measure that your intervention is working?
| Were you able to accurately measure how your intervention was working? What outcomes do you expect? At least 80% of providers adhere to HTN workflow and QI team runs a report to compare the state of the patient at initial visit and follows the patient’s progress for 3 months - this includes multiple metrics/measures: overall BP, HTN prescription and dosage, connection to social care resources after SDOH screening (Laura to pull report with test reports) | ||
What outcomes do you expect? At least 80% of providers adhere to HTN workflow and treatment protocol; consider looking at prescriptions by panel by provider (e.g., provider scorecard) to understand who is prescribing monotherapy, combo therapy, SPC, etc. | What outcomes have you seen? | How will you ensure your intervention will be effective for your target population?
| What unintended consequences or outcomes might there be?
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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.
| How will you know if clinicians/care teams/sites used the intervention?
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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? During internal meetings and huddles (cadence?) staff delivering the intervention can review data and discuss collectively how to adjust/pivot if necessary; Dr. Grubbs can also take feedback on implementing treatment algorithm, document any changes, and share back with the group involved in delivery (e.g., Anekaila, Kemberly, provider group) | What might be some of the possible obstacles to consistent implementation? Ensuring sustainability of the guideline-supported treatment algorithm Dr. Grubbs is implementing; ensuring that prescription behavior change for providers “sticks” and continues beyond a 90-day mark; ensuring that documentation on med intensification is consistent in the EMR | It is still early after pivoting to a new workflow, but the hope is that by addressing patient’s HTN needs (medical) including meds, with social needs (e.g., transportation has been identified a barrier to HTN treatment and care), BP is more managed and pts feel more empowered to take charge of their own health / improve their BP | |
How will you ensure your intervention will be effective for your target population?
| Did your intervention reach the target population? Yes, we are reaching AA adults, particularly those disconnected from care with CHA outreach calls | ||
What unintended consequences or outcomes might there be?
| What unintended outcomes did you experience? Staffing is a tremendous challenge at WOHC, making implementation of provider-led interventions for HTN particularly hard | ||
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.
| Who delivered the intervention? Did they have the skills and time needed to complete the intervention? NP Kim, CHA team, health educator - yes having a clinician and community health advocate tag team will be incredibly helpful for a “holistic” approach to managing BP | ||
How will you know if clinicians/care teams/sites used the intervention?
| What proportion of the planned staff/sites implemented the intervention? About 20-30% of planned staff are taking part in intervention, so much lower than anticipated; this will be conducted on a smaller scale than planned; anticipated implementing at all 3 sites but will now be 1 site 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? During internal meetings and huddles (cadence?) staff delivering the intervention can review data and discuss collectively how to adjust/pivot if necessary; Dr. Grubbs can also take feedback on implementing treatment algorithm, document any changes, and share back with the group involved in delivery (e.g., Anekaila, Kemberly, provider group) | How did you track modifications during the intervention? | ||
What might be some of the possible obstacles to consistent implementation? Ensuring sustainability of the guideline-supported treatment algorithm Dr. Grubbs is implementing; ensuring that prescription behavior change for providers “sticks” and continues beyond a 90-day mark; ensuring that documentation on med intensification is consistent in the EMR | What were the barriers to consistent intervention implementation? Establishing care with new patients (first time appts) - long time out for appts - some assigned to providers who are gone and need to establish care with current provider | ||
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: | How will you spread your intervention and lessons learned?
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Intervention #2
Plan
Intervention #2
Actual
Describe Intervention
(Select ONE; useBPAA Project Roadmap for ideas on evidence-based strategies)Chosen intervention: targeted patient outreach messaging using MyChart bulk communication feature and central phone calls
Plan for intervention: WOHC plans to use central phone calls and bulk communications to reach out to patients. They will be targeting patients who need to come in for a visit who have not been engaged in care. For noncompliant patients, the plan is to send them information about resources and community health offerings through educational flyers. If a patient replies to a MyChart message their reply will go directly to a Community Health (CH) advocate who will then contact them to discuss appointment scheduling and resources over the phone, including SMBP. For patients with an appointment scheduled, messaging will be used to send them a reminder. The CH team will develop separate messaging for Million Hearts patients after pulling a patient list from WorkBench. Separate, culturally competent educational materials will be created for this population.
Chosen Intervention: targeted patient outreach messaging using MyChart bulk communication feature and central phone calls
Date when implemented: September/October 2023
Updates:
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention)
Reach of implementers/providers?
Planned:Reach of implementers/providers?
Actual:
Reach of patients (# of patients receiving treatment intensification)?
70/556 (no therapy) and 164/556 (monotherapy)
Reach of patients (# of patients noncompliant BP)?
556/1437
*numerator is number to target for this intervention
Planned:
# AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023): 70
# AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023): 164
# AA pts. w/uncontrolled HTN (as of 6/30/2023): 556
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?
We will measure impact on overall BP control measure (AA Adults BP Control (past 12 months)); CH team can also track a subset of all noncompliant patients by analyzing the BP reading data for patients on outreach lists who reply to a MyChart message and schedule an appt. The team can also track the “no show” rate for these patients to see if outreach and scheduling is effective. We will also track number of patients on no HTN medication.
Were you able to accurately measure how your intervention was working?
What outcomes do you expect?
We would expect BP control to increase for patients responsive to outreach and who schedule an appointment. We may also see a decrease in the number of patients on no HTN medication if patients newly engaged in care are coming into the clinic for a visit.
What outcomes have you seen?
How will you ensure your intervention will be effective for your target population?
Re-engage patient with medical and community health services.
Provide HTN and medication educational material after visit to encourage patient to practice HTN self-management from home.
Provide educational material to help patients engage with provider in follow up appointments.
Community health advocate (CHA) will also be tracking patient’s BP after every visit with provider so can see impact on MH population; QI team will generate lists of patients with recent visits and review whether they are on anti HTN medication or not – the goal is that the number on no anti HTN from MH patient list will be decreasing.
Did your intervention reach the target population?
What unintended consequences or outcomes might there be?
High No Show and cancellation rate
Provider turn over
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.
QI team will create list of AA HTN pts who have not had a visit in the measurement period and pts on no anti HTN medication without a visit in the measurement period; Community Health Advocates (CHA) will identify patients with active MyChart accounts and send informational flyers to pts; this will happen across sites
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?
CHAs and QI team will communicate to check in on the intervention and their ability to work through outreach lists; will also discuss the engagement rate and no show rate at team meetings
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?
CHAs meet monthly to discuss existing projects - Laura presents data to them that is relevant to project and overall HTN rate - can discuss barriers to interventions that need to be addressed and will pivot if needed
How did you track modifications during the intervention?
What might be some of the possible obstacles to consistent implementation?
Staff outreach capacity - one CHA currently and thinking through how to best utilize her team to have implementation work ongoing at both sites
Pt engagement - # of responses from outreach messaging (want pt to continue to work with health coach and create small goals to keep them engaged - thinking of f/u strategies to make sure they remain engaged - considering a screening for SDOH to address barriers to coming in for appts (e.g., transportation)
There will be a big upfront time investment for Dr. Grubbs to train existing and new providers on workflows and ensure sustainability with consistent check-in calls or team huddles; there is an opportunity cost to training – it could pull clinicians away from other tasks and responsibilities. This could be particularly challenging with clinic staff capacity issues. WOHC continues to hire provider and RN staff so we can closely monitor the impact of this initiative on staff workload/capacity. | 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: | What reinforcements did you put into place to sustain the intervention?
Explain: |
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; useBPAA Project Roadmap for ideas on evidence-based strategies) Chosen intervention: targeted patient outreach messaging using MyChart bulk communication feature and central phone calls Plan for intervention: WOHC plans to use central phone calls and bulk communications to reach out to patients. They will be targeting patients who need to come in for a visit who have not been engaged in care. For noncompliant patients, the plan is to send them information about resources and community health offerings through educational flyers. If a patient replies to a MyChart message their reply will go directly to a Community Health (CH) advocate who will then contact them to discuss appointment scheduling and resources over the phone, including SMBP. For patients with an appointment scheduled, messaging will be used to send them a reminder. The CH team will develop separate messaging for Million Hearts patients after pulling a patient list from WorkBench. Separate, culturally competent educational materials will be created for this population. | Chosen Intervention: targeted patient outreach messaging using MyChart bulk communication feature and central phone calls Date when implemented: September/October 2023 Updates: 2/26/2024: added CHA education components (educational bundle) to work with patients on managing BP, creating lifestyle goals; pivoted from using a flyer to direct telephonic outreach to reach patients; moving away from MyChart outreach but may still add this in as a supplement depending on how telephonic outreach continues to go |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: | Reach of implementers/providers? Actual: 1 CHA, MA staff |
Reach of patients (# of patients receiving treatment intensification)? 70/556 (no therapy) and 164/556 (monotherapy) Reach of patients (# of patients noncompliant BP)? 556/1437 *numerator is number to target for this intervention Planned:
| Reach of patients (# of patients receiving treatment intensification)? Actual: ~200 patients on outreach list |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? We will measure impact on overall BP control measure (AA Adults BP Control (past 12 months)); CH team can also track a subset of all noncompliant patients by analyzing the BP reading data for patients on outreach lists who reply to a MyChart message and schedule an appt. The team can also track the “no show” rate for these patients to see if outreach and scheduling is effective. We will also track number of patients on no HTN medication. | Were you able to accurately measure how your intervention was working? Volume of patients who have responded to outreach is very low so hard to measure impact right now; still tracking the # of patients who have been called; considering blocking off certain days for telephonic outreach to manage high volume outreach list Update 4/10/24: volume still low but outreach stalled a bit after CHA left; looking to backfill with another CHA who can support outreach and education and connection to NP Kim for initial appt |
What outcomes do you expect? We would expect BP control to increase for patients responsive to outreach and who schedule an appointment. We may also see a decrease in the number of patients on no HTN medication if patients newly engaged in care are coming into the clinic for a visit. | What outcomes have you seen? TBD Update 4/10/24: completed 3 pt visits and connected them to BP clinic; no show and cancelation rate has been high and poses an access barrier |
How will you ensure your intervention will be effective for your target population?
Community health advocate (CHA) will also be tracking patient’s BP after every visit with provider so can see impact on MH population; QI team will generate lists of patients with recent visits and review whether they are on anti HTN medication or not – the goal is that the number on no anti HTN from MH patient list will be decreasing. | Did your intervention reach the target population? Still prioritizing AA patients who are disconnected from care; Liv focused specifically on the list of pts on no anti-HTN meds (~52 pts) before leaving WOHC |
What unintended consequences or outcomes might there be?
| What unintended outcomes did you experience? It has been challenging to get a response from patients and encourage engagement/trust for BP control; staff conducting outreach (CHAs) have to be trained in having these conversations with patients |
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. QI team will create list of AA HTN pts who have not had a visit in the measurement period and pts on no anti HTN medication without a visit in the measurement period; Community Health Advocates (CHA) will identify patients with active MyChart accounts and send informational flyers to pts; this will happen across sites | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? CHAs are mostly managing this - yes they bring a level of cultural awareness/sensitivity that helps with patient engagement |
How will you know if clinicians/care teams/sites used the intervention? CHAs and QI team will communicate to check in on the intervention and their ability to work through outreach lists; will also discuss the engagement rate and no show rate at team meetings | What proportion of the planned staff/sites implemented the intervention? Same CHA and QI team is implementing 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.)? Liv was only working at West, and working with pts at East was a challenge; Liv was planning to go to East clinic to meet with pt but they canceled; still working through a way to manage East pts |
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? CHAs meet monthly to discuss existing projects - Laura presents data to them that is relevant to project and overall HTN rate - can discuss barriers to interventions that need to be addressed and will pivot if needed | How did you track modifications during the intervention? This went according to plan - intervention was mostly kept the same - the only change was the actual CHA doing outreach - still falls under the same process (Laura reaches out and speaks to CHA to ensure they are trained/have all info) |
What might be some of the possible obstacles to consistent implementation? Staff outreach capacity - one CHA currently and thinking through how to best utilize her team to have implementation work ongoing at both sites Pt engagement - # of responses from outreach messaging (want pt to continue to work with health coach and create small goals to keep them engaged - thinking of f/u strategies to make sure they remain engaged - considering a screening for SDOH to address barriers to coming in for appts (e.g., transportation) | What were the barriers to consistent intervention implementation? Staffing capacity and staff transition has posed a challenge; following the exact workflow (small pt list but if it was a bigger set of pts would be harder bc workflow wasn’t 100% followed) - there was a specific place to document in Epic but this wasn’t always followed - could have to do with training generally and sometimes the info collected from pts is not straightforward so hard to structure documentation - reports were contingent upon this so would be good to have them follow workflow could consider more planning or roadmaps in the future with appropriate training and time to test |
What costs and resources (including time and burden, not just money) need to be considered? Up front time commitment for outreach and engagement; using budget for some “swag” to keep patient engaged | What costs and resources (including time and burden, not just money) need to be considered? Staffing and time to conduct outreach and education |
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: training necessary since WOHC is piloting this → ultimate goal of sustaining through a formal workflow | What reinforcements did you put into place to sustain the intervention?
Explain: |
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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