1. Population Hypertension Control in the
Accountable Care Organization
Health Services Quality Improvement Methods
MPH 0231
Spring 2013
2. Presentation Outline
• Background
• Pre-work:
– Team, stakeholders, etc.
– Shared knowledge etc.
• Charter
• QI tools
• Project plans
• PDSA cycle
• Reflection
3. Introduction
• Hypertension (HTN) is responsible for one in six
deaths among adults
– most common reason for office visits and prescription
drugs in the United States
• Nearly one in three adults has hypertension
– huge economic demands on health care(estimated
$73.4 billion)
• NHANES survey
– 46 to 51% of persons with hypertension control (BP
<140/90)
4. Barriers to Care
Poor BP
Control
Poor access to
health care
and
medications
Lack of
adherence
with long-term
therapy
Poor
understanding
of diagnosis
5. Population-Based Policy and Systems Change
Approach - IOM
Prioritizing
Population-
based
Strategies
Healthy
Lifestyle
Decreased
Sodium
Intake
Improved
Surveillance
and
Reporting
Increased
Physical
Activity
6. Population-Based Policy and Systems Change
Approach - IOM
Promote policy and system change approaches
Treatment
according to
guidelines
Remove
economic
barriers to
receiving
medications
Provide dietary
and physical
activity
counseling
7. Stakeholders for QI Team
Stakeholder
Groups
Role Why? Unique perspective?
Patient Team Member Inform strategies for behavior change among
this population.
Primary Care
Physician
Team Member Knowledge of patient condition, patient
medical history, treatment options, standards
of care.
Nurse Team Leader Knowledge of patient condition and care,
hospital operations.
QI
Officer
Team Member/Subject
Matter Expert
Unbiased perspective, experience with QI
process
ACO
Leadership
Sponsor Wants to control population hypertension,
needs to meet high quality standards of care
while controlling costs for the ACO.
Health
Educator
Team Member/Subject
Matter Expert
Expertise in educating patients.
8. Team Roles and Responsibilities
Team Member Role Responsibility
Mio Various roles will
be shared
Lead/Scribe for Stakeholder, Team Agreement, Shared
Knowledge
Shared knowledge task: Change Strategies at the
population level
Hee-Jae Various roles will
be shared
Lead/Scribe for 3 QI, Charter, PDSA
Shared knowledge task: Measures of population HTN
management
Lauren Various roles will
be shared
Finalize PowerPoint presentation
Shared knowledge task: What population health means for
an ACO
Monica Various roles will
be shared
Presenter
Shared knowledge task: Benchmark 3 hospitals in MA using
Hospital Compare
Jay Various roles will
be shared
Presenter
Shared knowledge task: Definition of HTN, prevalence, risk
factors at population level
10. Hypertension Control
Goals of Accountable Care Organization (ACO)
To control health care costs
Drive quality in health care
Improve population health*
• Improving medical care for their populations of patients!
• Attention not focused on social and public health issues
and socioeconomic factors
13. What is the root cause?
Patients don't know how to control
hypertension/non-compliant
They don't have the knowledge/ability they
need to do it.
Ineffective communication and non-standard
training by provider.
Providers assume that patients understand
hypertension management plan.
Patients don't express when they don't
understand.
There is no protocol for verifying
comprehension.
Problem:
Uncontrolled hypertension (BP>140/90 mmHg) in the ACO population
ACTION:
Set standards for communicating with patients regarding hypertension self-management
15. Change Strategies
Producer/customer
interface
Exit interview to check
comprehension
Sources
• Telemed J E Health. 2011
May;17(4):254-61. doi:
10.1089/tmj.2010.0176.
Epub 2011 Apr 10
• HHS service report
Focus on variation
Standardize the process
of patient’s recording
of blood pressure
Sources
• Telemed J E Health. 2013
Apr;19(4):241-7. doi:
10.1089/tmj.2012.0036.
Epub 2013 Mar 19
Focus on error
proofing
Send out reminders
to patients and
checklist for nurses
Sources
16. Charter
Process Measure
• Number of patients who received intervention
• Denominator: # of patients with hypertension visited
• Numerator: # of patients who received intervention
Outcome Measure
• Number of patients with controlled hypertension will be measured
• Denominator: # of patients with hypertension diagnoses
• Numerator: # of patients with hypertension diagnoses with BP<140/90
Balancing Measure
• Provider’s time take away from care will be measured
• Denominator: Average patient wait times before PDSA implementation
• Numerator: Average patient wait times during PDSA implementation
By 12 months from now, 80% of patients between the age 35-70 with diagnosed hypertension
will have BP under 140/90 mmHg.
17. Plan-Do-Study-Act
Objective:
Provider will engage 5 patients and/or caregivers per day for 2 weeks in
hypertension self-management methods during patient visit and verify the
status of understanding before proceeding to checkout.
Cycle duration
May 6 -20, 2013
Prediction:
80% of the patients and/or caregivers will demonstrate their understanding
of hypertension self-management methods
18. Implementation and Measures
After patient’s visit with the physician, nurse’s
aid engages patient and/or caregiver in
hypertension self-management methods
including:
Medication regimen
Diet modification
Increasing physical activities
Outcome measures:
Denominator: # of patients receiving hypertension self-
management methods
Numerator:# of patients correctly verbalizing hypertension
self-management to nurse’s aid
Process measures:
Denominator: # of patients receiving hypertension self-
management methods
Numerator: # of patients confirming the completion of
hypertension self-management methods upon check-out
Balancing measures:
Denominator: average # of minutes of patient wait times on
non-PDSA days
Numerator: average # of minutes of patient wait times on
PDSA days.
19. • Usefulness of QI tools in pinpointing problems
• Importance of patient perspective in designing interventions
Lessons learned
• Different perspectives pulled us in different directions
Barriers to success
• Different perspectives strengthened our final direction
Factors promoting success
Editor's Notes
Background – briefly mention that our presentation is based on the hypertension incident from class activity and that we have been assigned to hypertension management in the ACO population. We will talk about prevalence, health outcomes, etc about HTN and why it’s important we work on this issue.
Pre-work slides are pretty self-explanatory.
Charter
Fish diagram to define our problem and the flow chart to explain where we can make improvements.
Project plans – We will describe the overall project of improving communication of HTN management communication upon visit AND implementing a phone follow-ups for continuous monitoring.
PDSA cycle – this is our small PDSA cycle for education/communication at the clinic visit ONLY. It will contain the measurements for THIS cycle only here.
Reflection
Other stakeholders identified: patient’s family, home nurse, hospital leadership, dietician, community health worker, payers, ER physicians, EMTs, pharmacist, Department of Public Health, non-medical professionals such as care coordinators, case managers, receptionists, etc.
ACO’s could be criticized that they would be interested in improving the health of their own patients and not the population as a whole.
Show flow diagram here and explain the BIG project plan and our measures related to our AIM statement. We will point out how our small PDSA cycle fits into the big picture here.
This is where we are going to show the Fish diagram
Exit interview to check comprehension – Producer/customer interface – Literature on telehealth#1, HHS service report
Standardize the process of patient’s recording BP – Focus on variation – Lit on Telehealth #2
Send out reminders to patients and checklist for nurses – focus on error proofing – USD HHS services report under clinical inertia
Outcome measures: Nurse’s aid verifies patient’s understanding of the hypertension self-management components through patient’s and/or caregiver’s demonstration of understanding by verbalizing materials covered and personalized lifestyle modification goals.
Process measures: Administrative staff at the check out desk will ask the patient with hypertension diagnosis and/or the caregiver if the hypertension self-management session has been provided by the nurse's aid
Balancing measures: Administrative staff will record patient wait times and compare between days with and without project implementations
Usefulness of QI tools in pinpointing problems: the tools facilitate critical thinking that decreases assumptions and missed opportunities that come with not considering a wide range of strategies
