West Oakland Health Center Intervention Assessment

Internal Characteristics

What are the characteristics of your health center? (rural/urban; other demographic variables, use of expanded care team, culture)?  

most pts are Black/AA or Hispanic; @ WOH site primarily AA; East Oakland primarily Hispanic (most HTN between these two groups); high # of homeless pop - challenging to keep in outreach; community health dept handles outreach - hired health coach to utilize as educator (more focused on outreach and engagement than in clinic work)

How do interventions and/or workflows need to be adapted to ensure health equity?

lean on community health dept a lot to incorporate equity - help to identify barriers for pts - work with underprivileged communities so find ways to help pts prio health (e.g., need healthy food, provide gift cards, education, transportation) 

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)?

main barrier is understaffing which makes all workflows much harder to implement - saw the impact of this on most of their measures; provider schedules also adds to perceived difficulty - pts feel appts are so far away (TIME -appt availability - offer appt a few months out) that they end up not wanting to come in; BP clinic is helping to relieve that wait time and can address some of these concerns with a fully staffed community health dept and new providers currently onboarding

What are key characteristics of the participating setting(s)?

having an in-house pharmacy at WOH has been an enabler for medication-related interventions as it relates to HTN; BP clinic set up is also unique to WOH and can help with BP compliance

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: 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 - 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:

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

Planned: 70/556 (no therapy) and 164/556 (monotherapy)

• # 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

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?

• Measure adherence to treatment algorithm: looking for a decrease in patients on no therapy, decrease in monotherapy prescriptions, and an increase in combo therapy

• (adherence) Increased the percentage or number of patients with controlled BP

• Decrease the no show rate (will look for numbers on this internally)

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 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?

• Patient education ( RN education and other resources)

• Internal trainings for providers

• Ensure patient accessibility to transportation to medical appointments.

• Provide patients with food vouchers for food pharmacy

• RN follow up with patients (Anekaila to own this)

• Explore incentives for MH patients

Did your intervention reach the target population?

What unintended consequences or outcomes might there be?

• Issues with medication adherence after initial visits – keeping patients engaged

• High no show rate to BP clinic vists

• Provider and RN turnover

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.

• Dr Grubbs at East, West, and AJ Thomas

• Anekaila Crevani, RN at East, West, and AJ Thomas

• Kemberly Rodriguez at East, West, and AJ Thomas

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?

• QI and provider champion running chart review/audits.

• Peer review

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?

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?

What costs and resources (including time and burden, not just money) need to be considered?

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:

• 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: 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?

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:

• 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)?