How to Fix your HIPS Problem Meg Meador MPH CPHI Director Clinical Integration amp Education NACHC April 1 2016 Overview The problem of undiagnosed hypertension HIPS and why you should care ID: 513039
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Slide1Slide2
Undiagnosed Hypertension:
How to Fix your “HIPS” Problem
Meg Meador, MPH,
C-PHI
Director, Clinical Integration & Education, NACHC
April
1
, 2016Slide3
Overview
The problem of undiagnosed hypertension – “HIPS” – and why you should care!
What
you can do to address the
issue
Results from the NACHC
Million Hearts
project
Tools and Resources Slide4
Who is NACHC?
National Association of Community Health Centers (NACHC)
Founded in 1971
Our
Mission:
“To promote the provision of high quality, comprehensive and affordable health care that is coordinated, culturally and linguistically competent, and community directed for all medically underserved populations
.”
National Association and voice for health centers
Research-based advocacy
Education about the mission and value of health centers
Training/TA to health center staff and boards
Clinical Workforce, Innovation, PerformanceSlide5
The Problem of Undiagnosed Hypertension (and why you should care)Slide6
Hypertension Prevalence and Consequences
75 million U.S. adults have hypertension (HTN)
1
Every 44 seconds, someone in the U.S. has a heart attack2
Every 4 minutes, someone dies of a
stroke
2
1 out of every 3 adults dies from cardiovascular disease
U.S
. prevalence of HTN is
31% - how does your health center compare?
1
40.3% among non-Hispanic blacks
41.2% among adults 40-64
69.6% among adults 60+
National
Health and Nutrition Examination Survey, 2013-2014 CDCMillion Hearts
Why Should I Care?
It’s a huge problemSlide7
Uncontrolled HTN
Source: 2013-2014 National Health and Nutrition Examination Survey and Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC Slide8
“Unaware” – A Closer Look
Wall HK, Hannan JA, Wright JS. Patients with Undiagnosed Hypertension: Hiding in Plain Sight. JAMA. 2014;312(19):1973-74.Slide9
Why is finding patients with undiagnosed hypertension important?
Diagnosed hypertension patients:
100 adults with essential HTN (ICD-9: 401 or ICD-10: I10)
70 of those adults with BP <140/90 70% BP control
What if a practice has 50 patients with multiple BP readings ≥140/90 but do
not
have the official diagnosis?
100 + 50 adults with possible HTN
70 with BP <140/90 47%
BP control
Source: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC Slide10
Hypertension Costs
$31,106 for patients with
ischemic heart disease (IHD)
$17,298 for those with cardiovascular disease (CVD)
$
18,693 for those
without IHD
or
CVD1Annual per person expenses of treating HTN with outpatient visits and medication: $
784
2
Consider costs from a value-based model perspective – health system and shared savings, performance incentives
Wang
G, Zhang Z, Ayala C. Hospitalization costs associated with hypertension as a secondary diagnosis among insured patients aged 18-64 years.
Am J
Hypertens
2010;23:275-281.Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality, 2012
Why Should I Care?
It’s a huge health care cost
Estimated
average
costs for HTN-related hospitalization:Slide11
Hypertension and Health Outcomes
Life expectancy 5 years longer in those with normal blood pressure than those with high blood pressure1
Lowering
blood pressure by 5 mmHg diastolic reduces the risk of stroke by 34% and ischemic heart disease by
21%
2
Antihypertensive therapy
associated
with:
Franco
OH,
Peeters
A,
Bonneux
L, de
Laet C. Blood pressure in adulthood and life expectancy with cardiovascular disease in men and women: Life course analysis. Hypertension. 2005;46:280.
Law M, Wald N, Morris J. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health Technol Assess. 2003;7(31):1-94Chobanian AV, Bakris
GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension
2003;42:1206-52.
Why Should I Care?
Controlling HTN works
35
% to 40
%
reduction in
stroke
20
% to 25% reduction
in heart attack
Over 50
%
decrease in
heart
failure
3Slide12
They’re in Your Health Center
Where do you start?!
Consider . . .
How many patients in your organization are clinically hypertensive but undiagnosed?
How many preventable
heart attacks and strokes will happen as a result?Slide13
QI Foundations and Key StrategiesSlide14
Source: Adapted from TMIT Consulting, LLC
The QI Trifecta
Successful QI Projects are Win-Win-Wins
Win!Slide15
QI Core Success Principle
Source: Adapted from IHISlide16
Key Strategies
Evidence-based/Emerging Successful Practices
Learning Community
Workflow Assessment/Redesign
http://www.healthit.gov/providers-professionals/clinical-decision-support-cdsSlide17
Key Strategies
The CDS 5 Rights Framework
To improve targeted care processes/ outcomes, interventions must provide:
the right information
e
.g., evidence-based guidance, actionable, response to clinical need…
[
what] to the right peopleconsider entire care team, including the patient… [who]
t
hrough the right
channels
EHR, population management system, smartphones
,
patient portal…
[where] in the right formatsdocumentation tools, data dashboards, registries, order sets, alerts… [how]at the the
right timesfor decision-making or action… [when]17
Source: TMIT Consulting, LLCSlide18
Leverage Expanded Care Team
Tools (registries, flow sheets, alerts, etc.) and Interventions
(nurse visits, staff training, motivational interviewing)Model
for Improvement/ PDSA CyclesNear real-time data
Change Package
Key StrategiesSlide19
How to Fix your HIPS ProblemSlide20
The BP Control Big Picture
The steps to find and address undiagnosed HTN fit here and should be part of your overall hypertension protocol that optimizes efficiency and effectiveness of diagnosing HTN
H
ow
do you manage a
HTN patient
you don’t know about?Slide21
Adapted from: Hilary Wall, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC
Steps for Finding and Addressing Undiagnosed Hypertension
Adapted from: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC Slide22
Putting it into Action
Adapted from: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC Slide23
Adapted from: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC
Putting it into ActionSlide24
Does your HTN Protocol Cover Diagnosis?
HTN Diagnosis Protocols
Obtaining accurate BP readings
Standardizing # readings/ # visits/ timeframe
“Assess
the patient for hypertension using the BP measure at initial visit and
repeated measurements taken at home or at office visits
.” based on JNC-7
??
What does this mean? How many readings? How many visits? In what timeframe?Slide25
Ambulatory BP Monitoring – USPSTF
Draft recommendations; public comment period closed 1/26/16
If made final, ABPM should be covered by most plans under ACA
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/hypertension-in-adults-screening-and-home-monitoring Slide26
Consider
importance/impactConsider
feasibility:
EffortTime
Cost
Tips for Choosing Change Strategies
Choosing Change Strategies
(Prioritizing Enhancements
)Slide27
NACHC’s HIPS ProjectSlide28
NACHC Million
Hearts “HIPS”
Project
Goals
Year 1
Year 2Slide29
Year 1 Aims
HIPS Project AimsSlide30
NACHC Million Hearts Partners
4
HCCNs
5 States10 Health Centers
At least 20,000 adult patients, ages 18-85 per network; actual: 150,000+
HCCN
PCA/HCCN
Central Valley Health Network (CA)
Health Center Partners of Southern California
Kentucky Health Center Network (KY/AR/TN)
Missouri Quality Improvement Network (MO)
Our PartnersSlide31
The Undiagnosed HTN Algorithms
Source: i2i Systems, Inc.Stage 1 Algorithm:
Patients ages 18 to 85 years without a diagnosis of essential or secondary HTN who have BP readings ≥140mmHg SBP or ≥90mmHg DSP at two separate medical visits, including the most recent visit, during the past 12 months
. OR
Stage 2 Algorithm:
Patients ages 18 to 85 years without a diagnosis of
essential or secondary HTN who
have a BP reading ≥160mmHg SBP or ≥100mmHg DSP at any one medical visit during the past 12 months.
Exclusions: pregnancy and ESRD.Slide32
How are the algorithms working?Slide33
Using HIT and Data to Inform QI
Who are the undiagnosed in Arkansas?
Women
- white, ages 18 - 39 with little obesity or depression
Source: i2i Systems, Inc.Slide34
Ah-Has
Patient engagement is a key step to addressing undiagnosed hypertension
There are no concrete diagnosis guidelines in the U.S
.!
Undiagnosed HTN clinical criteria needs
to achieve a balance between patient needs and provider
capacity
The
accuracy of blood pressure measurement is foundationalPlan your patient recall strategy
“HIPS
Exist! It’s one thing to hear about it and another to see real patient names on your own health center’s registry” – Grace Community Health Center
Slide35
Resources
Hypertension Prevalence Estimator Tool
- an online tool that may be used to calculate an expected hypertension prevalence among an ambulatory patient population
http://millionhearts.hhs.gov/tools-protocols/tools.html
National
Association of Community Health Centers’ Undiagnosed Hypertension
“HIPS” Change Package
–
a compilation of materials to help clinicians map and identify enhancements to clinical workflows that improve detection and diagnosis of HTN
http
://
mylearning.nachc.com/diweb/fs/file/id/229350/d/1
Hiding in Plain Sight Whiteboard
-
an animated video
that outlines concrete steps that can be taken to find potentially undiagnosed patientsSlide36
Undiagnosed HTN in the Field
Rakotz MK, Ewigman BG,
Sarav M, et al. A technology-based quality innovation to identify undiagnosed hypertension among active primary care patients. Ann Fam Med
. 2014;12(4):352-358.Shah NR. Identifying hypertension in electronic health records: a comparison of various approaches.
Paper presented at: AHRQ Comparative Effectiveness Research Methods Symposium; June 2009; Rockville, MD. Of Various Approaches. AHRQ Comparative Effectiveness Research Methods Symposium, Rockville, MD, June
2009
Banerjee D, Chung S, Wong EC, Wang EJ, Stafford RS,
Palaniappan
LP. Underdiagnosis of hypertension using electronic health records. Am J Hypertens. 2012;25(1):97-102.
Johnson HM, Thorpe CT,. Bartels CM, Schumacher JR,
Palta
M,
Pandhi
N, Sheehy AM, Smith MA. Undiagnosed hypertension among young adults with regular primary care use. J
Hypertens
. 2014, 32:65–74
NorthShore University Health SystemGeisinger HealthPalo Alto Medical FoundationUniversity of WisconsinHealth Center Network of New York
(article in progress)NACHC Million Hearts health centers
(article in progress)
Who’s Done it?