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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, use of expanded care team, culture)? | Urban, refugee/immigrant population, non-English speaking |
What are the infrastructure characteristics of your health center (use of expanded care team, culture)? | |
How do interventions and/or workflows need to be adapted to ensure health equity? | WYH is focusing on all patient populations with HTN |
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)? | Goal is to meet patient where they are at. |
What are key characteristics of the participating setting(s)? | clinic, face to face, phone |
External Characteristics : SDOH barriers, affording medication, limited insurance coverage, non-covered transportation. | |
What external or environmental supports or threats are there? | Supports: Unite Us Referral Platform to meet SDOH needs, not being able to meet patient needs due to a lack of insurance coverage and patient lacks funds. |
Treatment Intensification (Combination Therapy) Plan | Treatment Intensification (Combination Therapy) Actual |
Describe Intervention: Real time identifying patients that meet criteria for program. Nurse refers patient in clinic with BP 130/80 or > (Select ONE; use BPAA Project Roadmap for ideas on evidence-based strategies) Chosen intervention: Med adherence, pt. engagement. Plan for intervention: Nurse refers pt. to triage nurse who meets with pt. Triage nurse will refer to clinical pharm. | Chosen Intervention: Real time identifying patients that meet criteria for program. Date when implemented: Updates: |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Clinical Pharmacist working with providers to educate best practice related to evidence based guideline. Planned: Provider education/recommendations for med tx | Reach of implementers/providers? Actual: 2/15: did provide education with providers and importance on early intervention evidence base included was based on MH findings that Laurie has been sharing all along trying to use a provider peer to drive the need home for other providers |
Reach of patients (# of patients receiving treatment intensification)? Prescribed : 66%, 223/340 African American BP control 63%, 612/971. F/U appt scheduled with clinical pharmacist and provider. Planned:
| Reach of patients (# of patients receiving treatment intensification)? Actual: 2/15 AA Uncontrolled htn guideline therapy 83% 286/344 (3/1/23 - 2/29/24)
update on relevant data - felt cohort numbers were low - something wasn’t turned on |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? | Were you able to accurately measure how your intervention was working? 2/15: are able to click on the provider in relevant to see how they are doing CMO and Laurie have had conversations about posting data as visual reminder - not punitive but just highlighting need to focus on this |
What outcomes do you expect? Goal: improved medication ordering data for patient newly dx. with HTN | What outcomes have you seen? African American Adults w/uncontrolled HTN prescribed rec. therapy: 84.1% 288/346 covering period: 4/1/23-3/31/24. (this is improved data). This data implies that we are prescribing and ordering anti-hypertensive meds. Request made for a second data validation with Relevant/Health Efficient, as the numbers on this measure show some providers in the 50% range. Those same providers under the Uncontrolled African American Adults w/uncontrolled HTN and no Anti HTN medication therapy is 2.0% and 25%. 14/346 4.0% (4/1/23-3/31/24); African American Adults w/uncontrolled on Monotherapy: 70/346 20.2% (4/1/23-3/31/24) Continues data validation needed due to staffing deficit and inconsistent workflow around medication reconciliation process. Medlist not always updated to reflect most recent medication and or discontinued medications. |
How will you ensure your intervention will be effective for your target population? Team meets every 2 weeks to discuss referrals patient engagement, barriers and options to overcome barriers. We measure based on the data collected when we meet. Evaluate what is working and what is not. | Did your intervention reach the target population? Our interventions reached beyond the target population internally as WMY was also focusing on other populations/ethnic groups for (Health Equity) and not just African American Populations. Our Team is following many populations in the Million Hearts Program to ensure good health outcomes for all populations in line with our Mission/Vision at WMY. |
What unintended consequences or outcomes might there be? Providers not fully engaged with evidence base treatment recommendations. patients lack of engagement. | What unintended outcomes did you experience? The logic behind the data. The need to validate the data for a second time was not expected and influences the results to this program. Data is the driver towards “the know” Related to our Harvest Goal: The team is also creating patient awareness with HTN by wearing buttons on our lapels and posting posters asking patients if they know their numbers. This has had positive outcomes with a patient’s daughter referring her mother to the Million Hearts Program. The daughter was present for her Behavioral Health Appointment, and viewed the poster in the waiting area. All Team members are participating in the creating patient awareness goal. |
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? Clinical Pharmacist has been actively looking ahead on the providers schedule to conduct pre-visit planning to ensure the patient is on the recommended evidence based medication therapy treatment for HTN. She is also meeting with patients to ensure patients are educated regarding their medication and the pro/cons to taking the medication to ensure no further advancement to chronic disease and prevent heart attack and stroke. She share her recommendations with the provider for any needed medication changes. Clinical pharmacist is also meeting with patients on a regular basis as part of Million Hearts Program. | |
Who will deliver the intervention (actually do the work)? Include staff and sites, if applicable. Triage Nurse, Care Management, clinical pharmacist. All clinic locations. Nursing staff has been educated to send referrals via Athena and verbally, in real-time as patient is seen in clinic with HTN to Triage Nurse who will see patient or reach out to them via phone in real-time. Clinical Pharmacist can also see patient if Triage Nurse is not available. | Who delivered the intervention? All areas/services/all clinic locations. Did they have the skills and time needed to complete the intervention? WMY Team has re-pivoted workflows throughout the year of 2023 due to staffing deficit. The RN Triage Nurse, RN Care Manager, and Clinical Pharmacist have been the main team members to outreach to patients in real time and follow patients for Million Hearts. The Clinical Pharmacist provided education to the LPN Nursing team rooming patient related to taking a proper Blood Pressure. WMY data collection on second blood pressure revealed the need to re-educate LPN Team in February. LPN Team educated by Sr. Director of Care Management to Million Hearts Program workflow/patient identifier and how to refer a patient to the program. LPN staff also educated to pre-visit planning and how it relates to the program and the patients positive health outcomes for medication adherence/patient education. |
How will you know if clinicians/care teams/sites used the intervention? Data collection. We are monitoring second BP reads and how many of those patients are referred to Triage Nurse to start patient education and engage patient to Million Hearts Program. | What proportion of the planned staff/sites implemented the intervention? The projects plan was to ensure all sites were engaging in the program 100%. Staffing changes/deficit/new hires revealed that the referrals to RN triage had declined. Continuous education is key to ensure that we are following our workflow in all aspects of the project. Monthly meetings with triage and Clinical Pharmacist have been instrumental to identifying workflow opportunities and ensuring we are capturing patients who qualify for Million Hearts Program in real-time. 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.)? Staff deficit/New Hire staff definitely had an impact on workflows related to referring patients in real-time to Million Hearts Program as well as ensuring the accuracy of blood pressure reads during the intake process. Pre-visit planning was also an opportunity to ensure LPN staff were looking at medications (anti-HTN) asking patient if they are taking medications. Any side effects patients are reporting, the patient then should be referred to clinical pharmacist as well as RN Triage Nurse. (for all clinic locations). |
Implementation Fidelity (How closely the staff/sites followed the intervention design, delivered it as intended – also called fidelity to the intervention)re-education is definitely a need on a regular basis. We decided as a team to ensure there is education related to workflow, referring patients, how patient qualify for the program, pre-visit planning pointers on a quarterly basis related to HTN/preventative chronic disease management. Sr. Director of Care Management and Clinical Pharmacist would deliver the education. This not only includes the LPN Staff rooming patients, but also the provider staff. | |
How will you know what adaptations or modifications were made during the intervention? Tracking data and recording every two-week team meetings. | How did you track modifications during the intervention? Documenting meeting discussions and opportunities identified to adjust or change workflow as well as provide staff with more education or re-education. Making Million Hearts a part of our daily discussion has encouraged staff engagement. |
What might be some of the possible obstacles to consistent implementation? The pace of the clinic, other real-time identified needs. | What were the barriers to consistent intervention implementation? Real-time needs and staffing deficit that has led to several workflow re-pivots. |
What costs and resources (including time and burden, not just money) need to be considered? Enough staff to carry out the work. | What costs and resources (including time and burden, not just money) need to be considered? Staffing deficit is a huge burden. Keeping the enthusiasm of the program alive. Staffing changes often feel as though we are starting over to keep all engaged. If the staff is engaged, the patient is more likely to be engaged. If all staff (LPN, Providers ect.) are sending the same message in regards to the program for Million Hearts, it is more likely to engage the patient for successful health outcomes. |
How closely did the staff/sites follow the intervention design and deliver as intended? The data is monitored every two weeks when we have our check in meeting to evaluate our progress/barriers etc. Two education sessions has been delivered to nursing staff regarding taking second BP and referring HTN patients to Triage Nurse to follow with patient. | Check all that apply: Delivered somewhat consistent apply to the times that there were staffing changes/deficits and having to re-pivot workflows and re-educate staff to new workflow.
Modifications made and other notes: Workflow re-pivots based on staffing needs. |
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? Data is the driver to effective outcomes. We will continue to meet every two weeks as a check in to evaluate workflow barriers or need for change to workflow and or staff education needs.
Explain: We are working with marketing team to create patient awareness with a banner for clinic asking patients if they know their numbers Staff will also wear a button type pin on uniform with same message. | What reinforcements did you put into place to sustain the intervention?
Explain: Routine re-education to Million Hearts workflow, how to take a BP properly, and evidence-based medication treatment uncontrolled HTN (for all new staff (LPN/Provider). Meeting regularly with the team to evaluate as a team how the workflows are working. Reviewing the data as a team to determine if the provider/LPN staff is identifying/referring patients to Million Hearts Program. Reviewing second BP data to identify a decrease in populations requiring a second BP after the initial (130/80) as the identifier. We identified as a team when meeting regularly that we had an increase in the need for second BP. Clinical Pharmacist then planned education with DON to re-educate all LPN staff/all clinic locations. |
How will you spread your intervention and lessons learned? Education / Updates to project sharing data with providers and staff. | How will you spread your intervention and lessons learned? Continue the work. Expand to the community and other organizations that assist our patient with social drivers of health. Introducing and speaking to the program and the positive impacts it has had on all patient populations here at WMY. Work closely with our marketing team to ensure we are providing community education and posting to our website (know your numbers) for all patients to consider. We have seen our main health plans data improve around Cardiovascular Prevention. |
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)? Working/expanding program to include CBO to collaborate with WMY on Million Hearts Program. Many CBO’s follow our patients in the community such as Health Homes, Community Health Workers, Care Coordinators in Rehabilitative Support Programs for those patient with Mental/Behavioral Health needs. A “whole patient” approach is needed. WMY is also in the beginning stages of developing a RPM/RTM Model of care that includes a Medical and Behavioral Health component. This will allow WMY to offer an additional service for our patients that will allow access to care and close the gaps to Health Equity. Patient with HTN are one of the patients we will be following for the RPM/RTM. | |
Intervention #2 Plan | Intervention #2 Actual |
Describe Intervention - Statin Therapy and HTN: needs identified by looking at “whole patient” diagnosis such as DM, HTN, elevated LDL > 190 or hypocholesteremia, ASCVD are the focus. Triage Nurse, clinical pharmacist and Care Manager following patient will review chart to ensure patient is identified as qualifying for statin treatment (missed opportunity). The team ensures patient has a follow up apt. in place. Triage nurse will refer patients to clinical pharmacist to make recommendations to provider for statin therapy. Health Equity focus: All populations with HTN/Statin Therapy. (Select ONE; use BPAA Project Roadmap for ideas on evidence-based strategies) Chosen intervention: Identify patients with diagnosis of HTN and DM not on statin therapy who are being followed for HTN and or any triage patient calls the triage nurse is consulted for (triage nurse refers patient to clinical pharm.). Plan for intervention: Triage nurse, clinical pharm. and Care Manager will inform provider of patients need for statin therapy. Team meets twice per month to discuss patients being followed for HTN/Statin therapy. Challenges to patient outreach, patient engagement, patient engaged plan of care discussed and consider workflow changes to challenges identified. Banners and buttons created for patient awareness to HTN/Statin/DM | Chosen Intervention: Evidence based Guideline treatment recommendations: Antihypertensive medications for patients with uncontrolled HTN. Statin therapy prescribed for those patients with a HTN/diabetes diagnosis, and elevated cholesterol risk. Date when implemented: Post Million Hearts Harvest Meeting (June 2023). Updates: Clinical Pharmacist has been active in real-time reviewing patient scheduled as a “pre-visit” plan approach to evaluate patients medication needs and or if the medications prescribed are in fact working for the patient and align with the evidence based recommended treatment regimen. She has been an asset to the providers in providing appropriate recommendations. Meeting with Triage Team Monthly: Triage states that Nursing Team has not sent referrals to Triage for Million Hearts since Mid November 2023. Plan to re-educate Nursing Team. Second BP Check Data pulled from the month of December shared with Triage Team to work list and out reach patients on list. |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: 7-8 providers | Reach of implementers/providers? Actual: 7 adult providers and 2 OB providers |
Reach of patients (# of patients receiving treatment intensification)? Triage nurse following 30 patients for both statin and HTN. Care Managers identifying transition of care patients (HTN/Statin) approx. 20 patients per week. 7-8 providers, 4-5 providers the nursing staff conduct pre-visit planning to identify missed opportunities. Planned:
| Reach of patients (# of patients receiving treatment intensification)? Nursing Staff and pre-visit planners conduct pre-visit planning for providers. Clinical Pharmacist is also conducting a pre-visit medication need for those patients being seen for HTN and or any follow up appointment types on the schedule for HTN. Clinical Pharmacist is also conducting a medication rec. for all patients who are Transition of Care with 10 or more medications. Triage is following 30 patients currently for Million Hearts Program. 2 adult Care Managers are following 75-100 patients each. Majority of their patients are Transition of Care Patients, HTN, DM (In addition to other Chronic Conditions). One OB CM following 3 African American patients with HTN and + Permanency. Actual: Met with Relevant in 12/2023 to review data collected for Million Hearts Project and how it is being pulled from Athena for Validation. Relevant is to report back to the team once validation is complete. 11/30/23: African American with uncontrolled HTN on Monotherapy: 73/327 (23%) 12/31/23 African American with uncontrolled HTN on Monotherapy: 13/327 (22%) 1/31/23 African American with uncontrolled HTN and not treated with medication: 7% 12/31/23 African American with uncontrolled HTN and not treated with medications: Currently Improved @ 4% 13/327 4/8/24: African American Adults w/uncontrolled HTN on Monotherapy 70/346 20.2% (April 1, 2023-3/31/24). 4/8/24: African American Adults w/uncontrolled HTN no anti-HTN Medication Therapy 14/346, 4.0% (April 1, 2023-3/31/2024). 4/8/24: African American Adults w/uncontrolled HTN Prescribed a Guideline Recommended Therapy 291/346 84.1%. (April 1, 2023-3/31/24). |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? 1. Met with Relevant in 12/2023 to review data collected for Million Hearts Project and how it is being pulled from Athena for Validation. Relevant is to report back to the team once validation is complete. 2. Pull Relevant data frequently for review. 3. Continue to meet with Triage Team, Care Management Team to review workflows and results (How are the workflows working?), How are patients engaging with the program? What are the opportunities for improvement of process and patient engagement? | Were you able to accurately measure how your intervention was working? Yes. Data has been helpful and meaningful to identify the need to validate our data with Relevant. We met with Relevant recently and currently waiting for those results. Monthly team meeting has been helpful to identify the opportunities and to ensure that all team members are following the workflow. This helps to identify any opportunities for re-educating staff to workflow. |
What outcomes do you expect? Increasing patient awareness with our patient awareness buttons/poster asking “do you know your numbers? Ask me.” Improving health outcomes by ensuring team is educated to the evidence-based recommendations provided around treatment of HTN and Statin Therapy treatment. | What outcomes have you seen? 1/8/24: Managed Care Organization (CDPHP) shared data: Whitney M Young Jr. is now 5 stars with Statin Therapy. Our Relevant data for HTN has continued to rise towards positive outcomes. 4/2024: Updates: |
How will you ensure your intervention will be effective for your target population? Continue to meet monthly with staff and share/review data with all staff, continue to provide education to team. Continue to create patient awareness as a prevention. | Did your intervention reach the target population? Yes. We are looking at both African American populations and any other population who are identified as exhibiting signs of/or actual HTN. |
What unintended consequences or outcomes might there be? Nursing staff diverting from workflow and not referring patient to Triage Team for Million Hearts Program. | What unintended outcomes did you experience? Improving our medication efficacy. This data has been challenging to get providers buy in. Currently it shows we are slowly rising towards positive outcomes. Updates: Medication reconciliation workflows are a challenge to ensure medlist are updated due to staffing deficit. This can influence data. |
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. Triage Nurse Team, Adult/OB providers, clinical pharmacist, Care Managers for Adult populations seen at all WYH sites: Albany clinic, Watervliet Clinic, Troy clinic, Swinburne Clinic (OB Population). This team has been working with providers to create awareness around the need for treatment related to HTN and or statin therapy. | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? Triage Nurse Team, clinical pharmacist, Care Mangers. They refer to the clinical pharmacist to meet with patient who are struggling with medication side effects or need additional education to assist patients with medication compliance. Clinical pharmacist meets with patients in real-time in the clinic to assist providers in this regard as well. Clinical pharmacist also offers providers other medication treatment alternatives (less side effects for example) to improve patients health outcomes and medication compliance. |
How will you know if clinicians/care teams/sites used the intervention? Frequent communication is key. Maintain Monthly meetings with teams to evaluate and take a deeper dive into data, opportunities related to workflow and patient engagement, evaluate if workflows are working and tweak them as needed for effectiveness, re-educate staff as needed based on findings. | What proportion of the planned staff/sites implemented the intervention? All clinic sites, nursing staff, care management staff, Adult/OB Providers 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.)? OB populations seem small. We have just begun to focus on OB populations for HTN treatment and hoping this data will increase in number. |
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? Documented Monthly meeting minutes, email correspondence with team, education/data sharing with provider team, Triage Team, Nursing Team, Care Management Team. | How did you track modifications during the intervention? Documenting results shared in monthly meetings with teams as we take a deeper dive into the workflow, patient engagement, to identify areas of opportunity. |
What might be some of the possible obstacles to consistent implementation? Staffing: Lack of providers, and nursing has open positions as well. | What were the barriers to consistent intervention implementation? Staffing challenges with Nursing/ Lack of providers/decrease access to schedule patients for follow up visits. |
What costs and resources (including time and burden, not just money) need to be considered? Having enough staff to participate in the program. Monthly Meeting participation, workflows being followed to achieve the positive health outcomes and goals set for the program's success. | What costs and resources (including time and burden, not just money) need to be considered? Monthly meetings, outreach to patients require staff, purchase of buttons and posters to create patient awareness, data team time/awareness to validate data in our check in discussions. However, even though there is much time to achieve/accomplish these goals, this program has been useful to help our patients improve their lifestyles towards preventative, positive health outcomes. The data shred with WMY from our Managed Care Organizations reflect this work and the positive impact it is having towards the ultimate goal of a VBP arrangement. |
How closely did the staff/sites follow the intervention design and deliver as intended? We delivered constantly until staffing deficit/change occurs. We tend to loose consistent workflow and need to re-pivot to get workflow re-aligned. Check all that apply:
Modifications made and other notes: Nursing staff has been identified for the month of 12/2023 not referring patients to Triage Nurse Team for Million Hearts. Plan to re-educate Nursing staff to the workflow. Update: Nursing staff now reviewing medlist with patients at the time of pre-visit planning/intake and rooming patients to begin process to update medlist, with the goal to improve/validate data HTN. | |
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: Sharing the data and any new evidence-based education to keep providers informed on treatment | What reinforcements did you put into place to sustain the intervention?
Explain: Frequent sharing of data with providers. Also sharing any education related to evidence-based treatment related to HTN. Consistent Re-education (Qtrly) with all staff due to new staff onboarding frequently. |
How will you spread your intervention and lessons learned? Ensuring the team has frequent communication/discussion about what is working and what is not. | How will you spread your intervention and lessons learned? Monthly meetings with team to explore what is working and what is not for HTN. Sharing the data to encourage team to press on as it continues to improve. Collaborate with CBO who are working closely with our patients. |
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)? Frequent education with nursing staff/provider as new staff on-board. Continuous evaluation of Relevant data to ensure data validation. Continue to improve workflows to medication reconciliation. Clinical Pharmacist is a positive role addition to the current team and aides to support providers with recommendations. Also aides to educating patients in real-time and staff education. | |
| Version | Date | Comment |
|---|---|---|
| Current Version (v. 14) | Apr 18, 2024 17:40 | Jessica Ikard-Banks |
| v. 14 | Apr 18, 2024 17:40 | Jessica Ikard-Banks |
| v. 13 | Apr 18, 2024 17:26 | Jessica Ikard-Banks |
| v. 12 | Feb 28, 2024 19:04 | Jessica Ikard-Banks |
| v. 11 | Feb 15, 2024 19:50 | Chris Espersen |
| v. 10 | Jan 17, 2024 23:15 | Jessica Ikard-Banks |
| v. 9 | Jan 08, 2024 15:28 | Laurie Levasseur |
| v. 8 | Jan 05, 2024 16:44 | Lauren Becker (Deactivated) |
| v. 7 | Dec 21, 2023 20:04 | Chris Espersen |
| v. 6 | Dec 18, 2023 18:51 | Jessica Ikard-Banks |
| v. 5 | Dec 18, 2023 18:46 | Jessica Ikard-Banks |
| v. 4 | Oct 26, 2023 18:41 | Chris Espersen |
| v. 3 | Oct 26, 2023 18:00 | Jessica Ikard-Banks |
| v. 2 | Oct 26, 2023 17:52 | Jessica Ikard-Banks |
| v. 1 | Sept 18, 2023 20:11 | Lauren Becker (Deactivated) |
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