Hamilton Intervention Assessment

Internal Characteristics

What are the characteristics of your health center? (rural/urban; other demographic variables)?  

Hamilton Community Health Network (HCHN) is a FQHC in the Flint MI and surrounding areas with 8 mostly urban sites and 1 small rural site.

What are the infrastructure characteristics of your health center (use of the expanded care team, culture)?

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

SDOH are assessed and barriers addressed for all new patients, annually and when life situations change by protocol at HCHN. Staff must ensure these screening assessments are completed on all patients and all interventions related to SDOH addressed to ensure health equity.

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)?

Current lack of and transition of staffing will be our most difficult struggle to implementation.  Training staff may be disruptive at initiation and training must fit clinic schedule of training times.

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

Established in 1983, Hamilton is the largest FQHC in Genesee County with seven clinics and one clinic in Lapeer County. We have over 200 employees and a network of over 40 providers specializing in primary care/family medicine, pediatrics, obstetrics/gynecology, optometry, oral health, podiatry, behavioral health and psychiatry. Additionally, Hamilton has Michigan Medicine (University of Michigan) physicians and providers attend specialty clinics monthly. Those clinics include urology, gynecology, and breast health.

External Characteristics

What external or environmental supports or threats are there?

Hamilton is located in a food desert and transportation tends to be a barrier due to patients feeling unsafe on public transportation.

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: Patients with uncontrolled hypertension not on guideline recommended therapy and/or on monotherapy

Plan for intervention: Use Azara to identify and cohort patients with uncontrolled HTN and not on guideline therapy or monotherapy to show on patient visit planning report for morning huddle discussion.

Chosen Intervention:

Date when implemented:

Updates:

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

Reach of implementers/providers?

Planned: 100% of medical site staff will implement the use of PVP and huddle and discuss uncontrolled HTN not on guideline therapy or monotherapy.

Reach of implementers/providers?

Actual:

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

Patient goal- On no therapy- 8 patients

On Monotherapy- 21 patients

Planned:

• # AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023): 78 patients

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023): 213 patients

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? Monitor Azara DRVS for decrease of pts not on guideline therapy and/or monotherapy.

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

What outcomes do you expect? Decrease in 10% of patients with no guideline therapy and/or monotherapy.

What outcomes have you seen?

How will you ensure your intervention will be effective for your target population? Add this metric to monthly provider site meetings with interventions and expected outcomes.

Did your intervention reach the target population?

What unintended consequences or outcomes might there be? No movement in metric

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. Quality Team introduces the planned implementations during the monthly provider meetings and show metric and movement on measure. Care teams including staff nurses and medical assistants would be the ones pulling PVP and conduct morning huddles.

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? Decrease in the percent of patients in DRVS on monotherapy and an increase of those on guideline therapy.

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? This intervention is an agenda item on each provider monthly meeting and discussion of barriers and successes are addressed.

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation? Lack of consistent staffing, Provider apprehensive in changing prescribing practices, lack of provider engagement

What were the barriers to consistent intervention implementation?

What costs and resources (including time and burden, not just money) need to be considered? Staff do not engage in huddle or use PVP to identify and discuss patients to intervene and use interventions. Quality team members available to monitor interventions and pharmacy staff engagement into HTN control interventions.

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: Reinforcements will include HTN protocols, PVP alerts, training and regular reporting.

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? Use monthly site meetings to spread interventions, barriers to implementations and successes.

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: Expand care team encounters to include medication education and adherence coaching

Plan for intervention: Use PVP tool to identify uncontrolled HTN cohort and use soft handoff or referral for Health Educators to join care teams to preform medication education and adherence coaching.

Chosen Intervention:

Date when implemented:

Updates:

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

Reach of implementers/providers?

Planned: 100% site care teams introduced to expansion of care team intervention.

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): 78

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023): 213

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? Percentage of patients with uncontrolled hypertension will decrease and track referrals to health educators for hypertension therapy.

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

What outcomes do you expect? 10% improvement on BP control of the HCHN HTN cohort

What outcomes have you seen?

How will you ensure your intervention will be effective for your target population? Controlling BP measure will increase for AA cohort.

Did your intervention reach the target population?

What unintended consequences or outcomes might there be? Providers and care teams do not engage in education opportunity by utilizing the health educator or CHW to address barriers.

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. Quality Team introduces the planned implementations during the monthly provider meetings and show metric and movement on measure. Quality Director will introduce intervention during HE team meetings. Care teams will refer appropriate patients to the health educators who will conduct the education with the patients.

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? Referrals to HE for HTN control will increase.

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 control will improve and number of referrals to HE for HTN education will increase.

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation? Non-engagement of care teams

What were the barriers to consistent intervention implementation?

What costs and resources (including time and burden, not just money) need to be considered? Staffing struggles to continue implementation and stay focused on 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: Reinforcements will include HTN protocols, PVP alerts, training and regular reporting.

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? Use monthly site meetings to spread interventions, barriers to implementations and successes.

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)?