CHESPenn Intervention Assessment

Internal Characteristics

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

Two of our sites could be considered urban, Chester City, the only city in Delaware county and Upper Darby a large, diverse, densely populated municipality that borders Philadelphia.  Coatesville, is a small city in Chester county and is adjacent to rural areas, this site is a mix of both.  All three sites are majority minority, with sizeable immigrant populations and patients whose first language is not English.

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?

Addressing Digital Health Equity in SMBP: The staff responsible for program enrollment, SMBP Trainers, were prepared to address Digital Health Equity during the pilot period of our SMBP Program (2021-2022).  During this period, our staff attended SMBP trainings through the Million Hearts Collaborative, had one-on-one instruction with HFP facilitators who helped develop our workflow and technical knowledge.

In addition, during our training, we prepared for the obstacles that we expected such as language barriers, lack of knowledge of device (phone/tablet), outdated devices, pts without email and lack of wifi. While this was helpful, we learned more when working with patients, this is where our insight and skills to address the digital divide are best developed.   

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)?

Complexity of intervention implementation: Each step of the implementation has complexities which are characteristic issues seen with unfamiliarity, or a lack of mastery of their digital device.  Program implementation is generally less complex with patients who have intermediate mastery of their smart phone functions, including applications, email and settings. This group does better with device set-up and adherence to remote monitoring.  

The set-up, use and adherence with patients with an unfamiliarity is complex, patients do have a higher level of perceived difficulty, or actual difficulty and thus require more education, outreach and support.      

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

– A key characteristic is that we are a Federally Qualified Health Center providing care to a disparately affected and diverse patient population who experience high rates of chronic disease and health conditions such as hypertension.

External Characteristics

What external or environmental supports or threats are there?

An external support organization is the Health Federation of Philadelphia who have provided valuable assistance through the process of developing our program.  Threats?:  Ending of the Public Health Emergency effecting patient insurance access.  Shifting programmatic focus of funding organization.  Production issues causing reduction in supply of available blood pressure cuffs.   

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:

• Develop population health registries and point of care clinical decision support to identify:

Patients with uncontrolled hypertension

Patients with uncontrolled hypertension:

Not on a guideline-recommended therapy

On mono-therapy

Patients with undiagnosed hypertension

• Plan for intervention:

Utilize our new population health software, Azara, to create/disseminate a health registry, or tracking type, which will be accessible at point of care for clinical decision making.

Design new Million Hearts care gap dashboard and reports to address therapeutic inertia and control rates.

Continue to train clinicians on guideline-supported treatment algorithm (AMA Hypertension Treatment algorithm).

Continue SMBP program to support clinical decision making to address inertia and intensification.

Chosen Intervention: Develop population health registries and point of care clinical decision support

Date when implemented: January 1, 2024

Updates: The process to transfer to connect and migrate our historical and current EMR Data into Azara began in October 2023

12/19 - on pause due to Azara implementation, will use for pre-visit planning and distribute to care

teams in the morning, interest of residents in participating and they might be able to do a deep dive in chart reviews but also

potential of using Azara instead of having to do individual chart reviews

2/20: Mike is meeting with the Azara team on 2/20 to receive training on registries. An alert for patients with stage 1 HTN in the pre visit planning form has been created (Guideline Therapy). Replicating the dashboard done for other participants in the Million hearts programs.

movement of data to Azara has gone well. staff are asking for PVP and huddle sheets - are used to this! Excited about this as well

as SMBP referrals and the potential utilization of Azara.

4/9: Referral to clinical pharmacist for medication titration as per protocol.

Implementation Strategy for One Intervention (4/30)

Strategy Name: Data-Driven Clinical Decision Support to guide Treatment Intensification/SMBP

Strategy description (including who is the focus/target of the intervention): Developed population health registries and point of care clinical decision support to identify AA patients with uncontrolled hypertension and Monotherapy/Non Guideline-recommended therapy for Treatment Intensification/SMBP

Who enacts the strategy: Clinical Care Team (Providers, RN, MA, BHC), SMBP Trainers (Program Manager, Patient Engagement Specialist, Community Health Worker and QI Coordinator)

What specific actions, steps, or processes need to be enacted before the intervention can be implemented (e.g., enacting a new policy, developing a workflow, building a new report): Develop SMBP enrollment workflow, train QI staff on new population health software, build registry, integrate clinical decision support into SMBP workflow.

When is the strategy used (e.g., during each patient visit, during monthly QI meetings): Daily as it is a designed to be POC, weekly for pre-visit planning, and monthly during QI meetings.

What is the dose of the strategy (e.g., one 3-hour training): Variable (daily workflow and monthly planning meetings).

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

Reach of implementers/providers?

Planned: Intervention to be implemented across the organization.

Reach of implementers/providers?

Actual: Intervention has reached nearly all service providers, including Family Health, Internist, OB/GYN, Behavioral Health (LCSW), and Social Services, engaging these staff in various roles of our program.

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

Planned: All uncontrolled hypertensive patients - approximately 500 AA Uncontrolled HTN patients will be part of the registry*. (*AA Pts with last BP >140/90 during the reporting period-as of 6/30/23: 537)

• # AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023): 14/537

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023): 170/537

Reach of patients: The intervention was applied to the majority of our MH PTS:

Utilize Data-Driven Clinical Decision Support to guide Treatment Intensification/SMBP

Following AMA MAP Algorithm leading to Treatment Intensification

Enrollment in SMBP Program - Intensify Medication, Educate Therapeutic Lifestyle Changes (Diet, Exercise, Stress Mngmnt)

Reach of Patients: # of patients receiving treatment intensification - 348 / 1617 (MH Pts) = 21.5%

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working? Azara Dashboard and Analytic Report designed for chosen MH Intervention

Were you able to accurately measure how your intervention was working? Yes - Utilizing Population Health Tool-Azara

What outcomes do you expect?

A 10% increase in HTN Control with AA patients.

A 20% decrease in # AA pts w/ uncontrolled HTN on Monotherapy

A 10% decrease in # AA pts w/ uncontrolled HTN on No Therapy

What outcomes have you seen?

Actual: Trailing Year July 23 (TY_April23) vs. TY_April24 - Green (met goal); Yellow (approached goal)

MH Control Rate: TY_April23: 46.56% (671/1441) vs. TY_April24: 51.04% (808/1583)

MH Uncontrolled No Anti Htn. Meds: TY_April23: 13.60% (84/619) vs. TY_April24: 12.4% (86/692)

MH Uncontrolled Monotherapy: TY_April23: 34.2% (212/619) vs. TY_April24: 31.4% (217/692)

MH Guideline Therapy: TY_April23: 74% TY_April24: 72.4%

How will you ensure your intervention will be effective for your target population? Utilize a PDSA to review the workflow designed to best utilize the population health registries and point of care clinical decision support to identify AA pts w/ uncontrolled on Monotherapy or No Therapy.

Did your intervention reach the target population? YES

What unintended consequences or outcomes might there be? Patients might experience difficulty tolerating a particular combination of hypertension medications during the process of intensification. This could lead to reluctance from both patients and healthcare providers in considering the use of a second agent in the future.

What unintended outcomes did you experience? Some documented side effects of intensification were observed in charts during this program year, ex: not tolerating ACE or CCB due to side effects.

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.

Clinical Care Team and Office Manager at each site; Performance Improvement Coordinator, Program Coordinator and Patient Engagement Specialist.

Who delivered the intervention? Family Health, Internist, OB/GYN, Behavioral Health (LCSW), and Social Services; engaging these staff in various roles of our program.

Second Year and Third Year Family Medicine Residents did their Quality Improvement projects on our SMBP program,

as well as championing Million Hearts

Public Health Intern performed a Data Analysis of our SMBP Program.

Did they have the skills and time needed to complete the intervention? Yes

How will you know if clinicians/care teams/sites used the intervention? Dashboard, reports and chart reviews performed per PDSA

What proportion of the planned staff/sites implemented the intervention? 100%

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.): All of our Family Medicine providers adopted the intervention, especially the SMBP component, our Internists utilized SMBP not at the same level as Family Medicine. The Family Medicine Residency Program are champions of the program and thus the site where they practice had the most SMBP patients.

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? Tracking and reviewing the intervention PDSA

How did you track modifications during the intervention? Tracking and reviewing the plan at weekly and monthly meetings.

What might be some of the possible obstacles to consistent implementation? Dissemination and adoption of the registry at the point of care. Provider reluctance to intensify treatment, patient reluctance to intensify due to fear of side effects. Provider workload, issues addressing multiple problems in one visit.

What were the barriers to consistent intervention implementation? Dissemination and adoption of the registry at the point of care. Provider reluctance to intensify treatment, patient reluctance to intensify due to fear of side effects. Provider workload, issues addressing multiple problems in one visit.

What costs and resources (including time and burden, not just money) need to be considered? SMBP cuffs are an integral part of our approach but are a limited resource, how do we sustain access? Lack of insurance coverage for bluetooth enabled BP cuffs causing ChesPenn to take on that additional cost. Issues with reimbursement for clinical pharmacists. *Note: Keystone First pilot program does provide care coordination reimbursement for patients enrolled in SMBP; funds are used to support the overall program.

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: If intervention demonstrates a positive outcome, we will reinforce by continuing our iterative PDSA cycle, documenting policies/protocols, and include in our Quality Improvement plan approved annually by our board.

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? Through our MH network, Organizational QI mtgs and monthly staff meetings. AMA MAP hypertension protocol will be included in the ChesPenn quality improvement policy which is approved by the board annually.

How will you spread your intervention and lessons learned?

We will look to continue the Keystone First pilot program and seek other opportunities or partners to secure sustainability including clinical pharmacy reimbursement.

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: Improve Medication Adherence

Plan

Intervention #2: Improve Medication Adherence

Actual

Describe Intervention

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

Chosen intervention: Assess for non-adherence (e.g., questionnaires, pill counts, contextual flags, missed appointments, infrequent refills)

Medication Therapy Management: Expand care team encounters to include medication education and adherence coaching (Elective Strategy) via in-person or telehealth consultations with Rite Choice pharmacist.

Assess for non-adherence (e.g., questionnaires, pill counts, contextual flags, missed appointments, infrequent refills)

Offer solutions:

Prescribe low-cost generics.

Prescribe single-pill combination therapy.

Align prescription refills.

Approaches to address “forgetfulness”

Chosen Intervention: Chosen intervention: Assess for non-adherence (e.g., questionnaires, pill counts, contextual flags, missed appointments, infrequent refills)

Medication Therapy Management: Expand care team encounters to include medication education and adherence coaching (Elective Strategy) via in-person or telehealth consultations with Rite Choice pharmacist.

Date when implemented: 6/1/2024

Updates: Intervention concept to be presented to Internal Medicine and CRNP providers for discussion and approval before moving forward.

12/19 - contract forwarded to compliance officer for review, waiting on this - might need a CPA

01/24: We have shared the algorithm with all our providers. They have until the end of the week to comment.

Anticipating the CPA will be signed by early next week.

2/20: Algorithm shared with providers. Workflows need to be created.

4/15: Patients who may be in need of intensification are presented to the providers via huddle sheet/patient list or patients are referred to SMBP trainers for a warm hand-off at point of care for enrollment into SMBP and MTM program.

4/30: Mike ran some data on SMBP patients getting out of stage 2 to stage 1

Strategy Name (e.g., outreach, clinical decision support, clinician education, data reports, etc.): Describe how SMBP is supporting this (post-partum SMBP program)

Strategy description (including who is the focus/target of the intervention)

Who enacts the strategy (e.g., QI staff, clinicians, health center leadership, patients/consumers, etc.)?

What specific actions, steps, or processes need to be enacted before the intervention can be implemented (e.g., enacting a new policy, developing a workflow, building a new report)?

When is the strategy used (e.g., during each patient visit, during monthly QI meetings)?

What is the dose of the strategy (e.g., one 3-hour training)?

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

Reach of implementers/providers?

Planned: Intervention to be implemented with patients of Internal Medicine and CRNP providers at our Eastside site where a Rite Choice Pharmacy is located.

Reach of implementers/providers?

Actual:

Reach of patients (# of patients receiving medication adherence)?

Planned: A Medication Therapy Management (MTM) cohort of 15 - 20 of AA pts w/ uncontrolled HTN

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

Actual:

4/30 update: 15-25; ongoing and still in the planning

Efficacy (Impact of intervention on important outcomes)

How will you measure that your intervention is working? Track control rates, medication adherence and continuity of care with MTM cohort.

may also track refills but this does not = to medication adherence

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

TBD upon implementation.

What outcomes do you expect? A 75% control rate for AA Pts w/ uncontrolled HTN chosen for MTM cohort.

What outcomes have you seen?

How will you ensure your intervention will be effective for your target population? Cohort will be identified utilizing the Population Health Registry and provider referral of patients who would best benefit. Effectiveness will be best insured by utilizing a PDSA to review the workflow which will be designed to best utilize the MTM intervention.

Did your intervention reach the target population?

What unintended consequences or outcomes might there be? Providers become resistant to the intervention due to due to patient reluctance, or intervention roll-out delays/issues. We do not reach our target goal or percentage.

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. Internal Medicine providers, Family Medicine providers, CRNP, Rite Choice Pharmacy, Office Manager at the Eastside site; Performance Improvement Coordinator, Program Coordinator and Patient Engagement Specialist.

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? Dashboard, reports and chart reviews performed per PDSA

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? Tracking and reviewing the intervention PDSA.

How did you track modifications during the intervention?

What might be some of the possible obstacles to consistent implementation? PT comfort level with the MTM virtual, or in-person visits. PT keeping scheduled visits, adherence to guidance. How do we most efficiently communicate medication change with providers? This workflow is still being finalized, however, the process for which Rite Choice has access to make changes in the EMR (updating med lists and documenting) is still being reviewed and developed. Identifying why an eligible patient was not referred or outreached?

What were the barriers to consistent intervention implementation?

What costs and resources (including time and burden, not just money) need to be considered? The MTM visit may be reimbursable for Rite Choice. If there is a prolonged period of time from the state to provide proper guidance on reimbursement to clinical pharmacists, Rite Choice may have to consider its ability to continue pilot.

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: If the reports, dashboards and chart reviews demonstrate a positive outcome we will reinforce this program by creating decision support triggers in our EMR, MTM protocols, and training/mtgs b/t providers and pharmacists.

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? Through our MH network, Organizational QI mtgs and monthly staff meetings.

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)? : Investigate options for MCO reimbursement.