Bay Area Community Health Intervention Assessment

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Important Health Center Context Fill out this section during your planning process
Internal Characteristics
What are the characteristics of your health center? (rural/urban; other demographic variables, use of expanded care team, culture)?	Diverse population (including homeless). Some patients qualify under a special program called Care Neighborhood. Some patients utilize specialty clinics (like HIV). Needed to adjust to reach/expand to these patients. Used expanded care teams to address MH patients with special conditions (BP cuffs, nutrition, HTN clinics).
How do interventions and/or workflows need to be adapted to ensure health equity?	Same workflows implemented for all patients (BP cuffs were made available to all patients regardless of insurance). Made sure as many patients as possible had access to BP devices. Have a food pharmacy to help with nutritional needs. Gave advice to different ethnic groups on how they can improve their nutrition (recipe ideas, reducing sodium intake). Some MH patients also offered Recipe4Health (food farmacy + health coaching). Access to these programs were made available to all MH patients
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)?	Hard to convince providers to use combo therapy over monotherapy. Many difficult discussions/debates about effectiveness of combo therapy; also hard to bring providers together to huddle. Difficult to coordinate a time that works for the entire staff.
What are key characteristics of the participating setting(s)?	To be answered for October submission
External Characteristics
What external or environmental supports or threats are there?

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: Expanded nurse-run hypertension clinics with provider involvement

Plan for intervention: Plan is to have one nurse on Tuesday seeing all HTN pts and 3-4 providers working on that day will be educated on HTN workflows; nurse will bring in one provider to review, change, or continue meds for pts; nurse will also prompt/nudge provider by having a covered formulary list (recently developed) and providing any necessary education on meds to streamline care; nurse will continue to offer training on guideline-supported treatment algorithms and will have regular 3-6 month follow up with providers to assess pt compliance

Chosen Intervention: nurse-run hypertension clinics with provider involvement

Date when implemented: planned for mid-October 2023

Updates:

Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention)

Reach of implementers/providers?

Planned: 9 providers involved in HTN clinics (North locations)

Reach of implementers/providers?

Actual:

Reach of patients # of patients receiving treatment intensification)?

starting with 4 to 6 patients per clinic (2 to start with) and re-evaluate when started, will look at patients below

Planned: # of pts in panel per provider for hypertensive patients

# AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023):
# AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023):

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?

track the number of patients who came into the clinic and who has BP improvement (1-3 months after visit); can also track the number of patients who were intensified after clinic visit; nurse team plans to use an Excel for tracking pt list(s) and can add a note “meds were intensified” and run reporting use dot phrases;

Were you able to accurately measure how your intervention was working?

What outcomes do you expect?

would expect to see an increase in med intensification for target population based on increased provider education and involvement in med management/treatment planning; would also anticipate decrease in monotherapy prescribing as nurses continue to train on guideline-supported treatment algorithms as part of these “joint visits”

What outcomes have you seen?

How will you ensure your intervention will be effective for your target population?

combination of looking at the data being tracked and qualitative/narrative data with patients and implementers on how intervention is going/progressing

tracking by provider

Did your intervention reach the target population?

What unintended consequences or outcomes might there be?

outcomes could be other health maintenance metrics (mammos, paps, vaccines) could be addressed - nurses will be addressing this in Epic during HTN visits

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.

providers and care team nurses (HTN clinic nurses) at North locations

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?

tracking how many patients came in for HTN visits and how many were intensified

internal meetings/huddles to discuss clinics and progress being made; discuss issues or patient cases with Dr. Menezes (clinical champion)

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?

How closely did the staff/sites follow the intervention design and deliver as intended?

Check all that apply:

Followed as designed
Followed with minor modifications
Followed somewhat as designed
Not followed as design
Delivered consistently/as intended
Delivered somewhat consistently/somewhat as intended
Delivered inconsistently/not as intended

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?

Protocols
Clinical decision support (alerts, order sets, templates, registries)
Policies
Regular training
Regular reports
Incentives
Other:

Explain:

What reinforcements did you put into place to sustain the intervention?

Protocols
Clinical decision support (alerts, order sets, templates, registries)
Policies
Regular training
Regular reports
Incentives
Other:

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; use BPAA Project Roadmap for ideas on evidence-based strategies)

Chosen intervention: [intervention subject to change] piloting Best Practice Advisory (BPA) popup for MAs

Plan for intervention: Plan is to alert MAs that they need to re-check BP and enter this data into the EMR; working with IS team to put pop ups in place in the North location; Dr. Menezes is pilot sponsor

will be a pop up if BP is above limit - have to retake BP - a couple of weeks away from implementation. El Rio - two part BPA - one to recheck, 2nd bpa if 2nd one still elevated script to MA to reschedule 2 to 4 weeks - BACH interested in this suggestion. in scheduling column added DBP and SBP so can see who is out of range can see if need to address - at end of the day can see who left with out of range BP and think if did anything on this.

Chosen Intervention:

Date when implemented:

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)?

Planned:

# AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023):
# AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023):