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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)? |
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What does the infrastructure of your health center look like? (use of expanded care team, culture)? |
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How do interventions and/or workflows need to be adapted to ensure health equity? | better job of collecting SDoH data and needing to integrate into closing gaps (affording Rx and transportation, housing) |
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)? | Intervention plan is aligned with current organizational efforts and will require low to medium level of effort to implement |
What are key characteristics of the participating setting(s)? | key staff turnover (multiple-CEO, CMO, QI person) |
External Characteristics | |
What external or environmental supports or threats are there? | Medicaid PHE unwinding Medicaid redetermination COVID |
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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: registry lists of patients with uncontrolled htn on no or monotherapy and determine what intervention would be (e.g., script for patient to intensify medication, use Simplify your Pill Routine cards, other intervention that will focus on intensifying medication) Plan for intervention: have been validating and analyzing patient level data (ensure provider has seen patient, uncontrolled patients on no or monotherapy), put into dashboard to examine trends, choose a provider to pilot, may share at provider meeting with visual. Provide education on medication intensification
Utilizing free BP cuffs for patients - manual BP cuffs and document; bring back logs Diet and lifestyle modifications
Journaling - BP documentation; Behavioral health; Assessing HTN med compliance | Chosen Intervention: Focus on patients on no or monotherapy Date when implemented: Expected in March 2024 Updates: Met with Health Center project lead on 12/4/23 to confirm implementation plan 2/21/2024: Want to focus on provider champion who is going to implement intervention and share results with other providers. Have a meeting next week to confirm intervention plan. Also working through patient-level report on no/mono therapy. Once patients are identified, then involve patient coordinators for outreach and follow-up visit (or plan accordingly if they have a scheduled visit). CMO had provider education at beginning of project year on combination therapy (annotate in run chart)! |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 1 Provider | Reach of implementers/providers? Actual: 1 Champion provider identified |
Reach of patients (# of patients receiving treatment intensification)? TBD (for now a single provider’s patients with uncontrolled HTN on no or monotherapy Planned:
| Reach of patients (# of patients receiving treatment intensification)? Actual: Champion provider is working to implement intervention to 61 patients |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? Will assess champion provider performance versus baseline | Were you able to accurately measure how your intervention was working? |
What outcomes do you expect? look at number of appointments coming in for the month and determine a reasonable goal based on n, will do chart audits after the appointment to determine the result, also want to see if accidentally prescribing monotherapy. Goals will be increased as have success | What outcomes have you seen? Number of patients who have received medication intensification has increased in last couple of months. Champion provider is currently at 27%, working to improve results further |
How will you ensure your intervention will be effective for your target population? that patient does have the recommended medication prescribed | Did your intervention reach the target population? Yes, intervention plan was created to align with champion provider’s ongoing commitment for HTN control |
What unintended consequences or outcomes might there be? might have prescription, but will adherence be an issue, and won’t be able to look at this until subsequent visit | What unintended outcomes did you experience? Health educator is currently under utilized. Have plans to engage them more and to also provide at home BP education to 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. Identified champion provider | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? Champion provider (APN) has been delivering the intervention |
How will you know if clinicians/care teams/sites used the intervention? | 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? Modifications will be discussed during monthly check-in meetings between project leads | 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? Lack of structured empanelment of patients to providers |
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? BP cuffs for patients to monitor at home |
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? Provider meetings | 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: Improved patient engagement and increased frequency of follow-up visits Plan for intervention: 2 week follow-up for patients with uncontrolled BP - can be nurse visit for BP check or telehealth. Led by MA/nurse in exam room for scheduling Utilizing free BP cuffs for patients Diet and lifestyle modifications Referrals to RD Journaling Assessing HTN med compliance | Chosen Intervention: Date when implemented: Updates: |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 1 provider | 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? Review scheduled appointments | Were you able to accurately measure how your intervention was working? |
What outcomes do you expect? Increased patient touchpoints and improved BP control | What outcomes have you seen? |
How will you ensure your intervention will be effective for your target population? Monitor data for increased frequency of patient follow-up visits and documentation of BP measurements | Did your intervention reach the target population? |
What unintended consequences or outcomes might there be? Scheduling difficulties due to limited staff time to coordinate touchpoints | 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. | 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? | 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? Modifications will be discussed during monthly check-in meetings between project leads | 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: | What reinforcements did you put into place to sustain the intervention?
Explain: |
How will you spread your intervention and lessons learned? Provider meetings | 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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