Unity Intervention Assessment

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.

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; use BPAA 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:

Date when implemented:

Updates:

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?

Actual:

Reach of patients (# of patients receiving treatment intensification)?

Planned:

• # AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023): 718

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023): 945

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? Attendance at these visits and BP readings.

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

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?

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?

What unintended consequences or outcomes might there be?

What unintended outcomes did you experience?

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?

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?

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 Lead will meet weekly with NP Residents to debrief how the group visits worked.

How did you track modifications during the intervention?

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?

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?

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: 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?

• 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? Utilizing the HTN and Chronic Care Working Group meetings and Unity wide communications.

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: 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:

Date when implemented:

Updates:

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:

Reach of patients (# of patients receiving treatment intensification)?

Planned: 10,000+ messages sent out to patients with BP>140/90.

• # 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? 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?

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?

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?

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?

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?

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?

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? All modifications will have to be presented to the Chronic Care Program Manager and HTN Lead.

How did you track modifications during the intervention?

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?

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?

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: Regular reporting and following up with clinical staffing.

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? Utilizing the HTN and Chronic Care Working Group meetings and Unity wide communications.

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)?