Whitney Young Intervention Assessment

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:

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:

• # AA pts. w/uncontrolled HTN on no therapy (as of 6/30/2023): 25%, 84/340

• # AA pts. w/uncontrolled HTN on monotherapy (as of 6/30/2023): 20%, 68/340

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)

• # AA pts. w/uncontrolled HTN on no therapy (as of 2/15/2024): 5%, 16/343 (3/1/23 - 2/29/24)

• # AA pts. w/uncontrolled HTN on monotherapy (as of 2/15/2024): 21%, 73/343 (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?

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?

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?

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

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?

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 data and recording every two-week team meetings.

How did you track modifications during the intervention?

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?

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?

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:

• 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? 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.

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports (review every 2 weeks)
• Incentives
• Other:

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?

• 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?

Education / Updates to project sharing data with providers and staff.

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 - 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:

• # 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)? 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

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 star with Statin Therapy. Our Relevant data for both HTN and Statins has continued to rise towards positive outcomes.

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, DM, need for Statin treatment.

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.

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

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?

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:

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

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: 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?

• Protocols
• Clinical decision support (alerts, order sets, templates, registries)
• Policies
• Regular training
• Regular reports
• Incentives
• Other:

Explain: Frequent sharing of data with providers. Also sharing any education related to evidence-based treatment related to HTN/Statin

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. Sharing the data to encourage team to press on as it continues to improve.

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.