Hypertension Control

Part 1: Introduction

Part 2: Characteristics for Success: Hypertension Control

Part 3: Implementation of Quality Measure: Hypertension Control

Part 4: Improvement Strategies: Hypertension Control

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information

Part 4: Improvement Strategies: Hypertension Control 

The actual improvement process is composed of three steps that respond to the following questions:

1. What changes can an organization make?
2. How can an organization make those changes?
3. How can an organization know the changes caused an improvement?

It is important to understand that improvement requires change, but not all change results in improvement. Considering all of the possible changes that can be made to health care systems, considerable effort has been dedicated to creating various quality improvement strategies providing a framework that organizes possible changes into logical categories. Frameworks for change in health care quality improvement are known as quality models and have been tested to guide change. In fact, considering that there are limited resources to dedicate to improvement, most organizations adopt one or more quality models to guide their improvement efforts. There is not a right or wrong approach, and there are many areas of overlap in quality models. Experienced quality improvement teams often use multiple strategies to overcome challenges as they progress. Two approaches often used by teams that are working to improve Hypertension Control are the Care Model approach and the Critical Pathway approach.

The case study may be read in its entirety by clicking here.

The Case Study: The Improvement Journey

1. Care Model Approach: Implementing the changes described in the Care Model is a proven method to improve care delivery. The Care Model, as shown in Figure 4.1, is an organizational framework for change and is organized into six domains:
   1. Organization of Health Care
   2. Clinical Information Systems
   3. Delivery System Design
   4. Decision Support
   5. Community
   6. Self-Management Support
   
   Figure 4.1: The Care Model

   Changes within these domains can effectively leverage transformation of a current reactive care system to one that better supports care for preventative health measures, such as, Hypertension Control and chronic disease conditions. If an organization does not have general experience with the Care Model, reading the Care Model section before proceeding is recommended. The Care Model recognizes that care for Hypertension Control is ongoing and requires more proactive care than the health care system often provides. The Care Model is implemented to improve care by working in six domains, defined below, that transform the way care is delivered:

   Community-To improve the health of the population, a health care organization reaches out to form powerful alliances and partnerships with State programs, local agencies, schools, faith organizations, businesses, and clubs.

   Organization of Health Care-A health care system can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.

   Self Management-Effective self management is very different from telling patients what to do. Patients have a central role in determining their care and one that fosters a sense of responsibility for their own health.

   Delivery System Design-Delivery of patient care requires not only to determine what care is needed, but to clarify roles and tasks to ensure the patient receives the care; that all of the clinicians who take care of a patient have centralized, up-to-date information about the patient's status, and make follow-up a part of their standard procedures.

   Decision Support-Treatment decisions need to be based on explicit, proven guidelines that are supported by at least one defining study. A health care organization integrates explicit, proven guidelines into the day-to-day practice of primary care providers in an accessible and easy-to-use manner.

   Clinical Information System-A registry, that is, an information system that can track individual patients and populations of patients, is a necessity when managing chronic illness or preventive care.

   Definitions above adapted from the Institute for Healthcare Improvement Web site. ⁽¹⁶⁾

   In Table 4.1: Care Model Key Changes, key changes are presented that have been used successfully to improve Hypertension Control care within the Care Model framework.   

     

   Table 4.1: Care Model Key Changes

   Community	Organization of Health Care	Self-Management Support	Delivery System Design	Decision Support	Clinical Information Systems
   Obtain free or discounted resources from pharmaceutical firms, service groups, and health plans for: scales, meds, BP cuffs and education programs	Appoint senior leader to identify and allocate resources and remove barriers to implementation of Care Model components	Train patient care teams on importance of patient self-management support and value of each member which may lend to improving patient outcomes	Use registry queries to plan visits for patients, especially those with uncontrolled hypertension Care team to review patient's record prior to visit Determine potential areas of focus to improve BP control Contact patient to confirm appointment and to bring medications, medication list, and ambulatory BP readings	Provide comprehensive and on-going training to providers and care teams on all aspects of BP measurement and management based on their skill levels and knowledge	Develop a manual or electronic registry of patients with HTN; list can initially be limited to patients with uncontrolled BP
   Promote non-traditional partnerships for places to exercise, monitor BP, and healthy food,i.e., parks, transportation, health clubs, schools, YMCA, faith-based organizations, restaurants, barbers, and beauty shops [link to Appendix 2A]	Develop partnerships with other health care organizations interested in patient care and outcomes	Develop culturally- and linguistically- appropriate self- management support tools with demonstrated effectiveness	Develop innovative patient flow processes to ensure the implementation of appropriate interventions to improve BP control, such as support staff to: Flag charts of patients with uncontrolled BP on arrival Review patient's medication list and compliance prior to provider's encounter Assess patient's compliance with self- management activities prior to provider's encounter	Ensure providers have easy access to experts in BP and cardiovascular health, including cardiologists, endocrinologists and nephrologists In group practices, an internist or family practitioner with such interests may be developed and trained to provide expert support, especially for difficult-to-treat patients	Use queries and reports proactively to plan patient's care; queries can include a list of HTN patients per PCP with the last visit and BP reading
   Use of promotoras, community health workers, and faith-based community to reach out to the community for education and screening	Board and senior leaders receive regular reports on hypertension control indicators and barriers to achieving goals	Embed sustainable self-management support process in a redesigned delivery system	Use of multi-disciplinary care team--nutritionist, social worker, health educator, medical case manager Target patients with uncontrolled hypertension initially and spread to all patients	Adopt and use clinical guidelines in the organization	Provide information on BP trend (and indicating target BP) from registry/EMR to patient at time of visit
   Develop relationships with universities and their providers to place students and interns in community projects	Ensure that the Care Model is integrated into the organization's strategic plans	Provide tools for self-management support (weighing scale, BP machines, pedometer, etc.)	Provide innovative patient flow and visit types (planned and group visits, drop in visits for BP checks, etc.)	Integrate guidelines into daily clinical practice (use of flow sheets, etc.)	Use an EMR or manual registry to ensure that providers have immediate individual patient's BP trends
   Hospital and university linkages for specialty care	Senior leader is engaged; endorses and communicates content and progress to BOD and staff	Develop culturally-appropriate self-management approaches: promotoras/community health worker; group visits/support groups; stages of change model	Consistent and appropriate follow-up, especially high-risk patients using telephone, promotoras	Develop systems and mechanisms to facilitate communication between PCP, specialist, and hospital	Obtain and share BP control compliance data from the registry with patient care teams at defined intervals and in innovative user- friendly formats
   Reach out to the community with health fairs and community education	QI team is empowered to make changes	Patient-tailored collaborative goal setting with form and follow up; copy of goals given to patient and noted in designated area in medical record	Anticipate and plan the hypertensive intake visit to ensure timely registration and follow up with clinician	Provide feedback to providers from population data (results and compliance with guidelines and measures)	Ensure integrity of registry data by defining accountability for oversight and maintenance, e.g., cross train support staff for data entry, data validity via sampling or for data downloads for patient care teams
   Partner with State, local and community public health programs	Incorporate training in the models into the orientation of new employees and staff	Protocols and training for staff relating to self-management support	Ensure clinical case management services for complex patients	Use standing orders and protocols when appropriate	Establish a process for obtaining records from other providers
   Provide resources to assist an organization in continued education on cultural competency	Allocate resources and remove barriers for improving hypertensive care and access	Organize and/or provide patient support groups		Inform patients about guidelines pertinent to their care
   	Integrate attainment of hypertensive care goals into business, strategic and performance improvement plans	Create expectation that patient takes responsibility for scheduling and attending hypertensive visits
   		Use all staff interactions with patients as opportunities to assist in self-management goal setting and practices
   		Create mechanisms for patient peer support and behavior change programs, such as, group hypertensive visits

   This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.

    

   Note: An organization may choose to adapt and refine a tool to assist improvement for the measure, Hypertension Control. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

   The case study may be read in its entirety by clicking here.

   The Case Study: The QI Team

2. Critical Pathway Approach: As with all critical pathways, good performance relies on many different systems and processes working together efficiently. An organization is encouraged to map its own critical pathway for Hypertension Control or refer to the schematic in Figure 4.2. Often when a QI team maps its pathways, it readily can see how complex each step is. It is common for different team members to do the same step differently. Workflow inefficiencies become clear when an organization visualizes how each step is completed and the interdependencies among the steps. Some teams are overwhelmed by the possibilities of changes that can be made in their systems; others focus only on a specific group of factors.

   One way to organize the factors that have an impact on the systems is to consider that some are controlled by the patient, others are primarily controlled by the care team, and still others are inherent in the system of care delivery. All three sets of changes must be considered to improve systems of care. In general, these categories can be defined as follows:

   • Patient changes-efforts to support self-management efforts, patient engagement, and navigation of the care system
   • Care team changes-changes in job duties or work flow that assist to retain patients in care and ensure timely evidence-based hypertensive care
   • Health system changes-changes that have an impact on how care is delivered, independent of who does it

   A team should use the steps along the critical pathway to target improvements. For this measure, Hypertension Control, an organization can think through each part of the critical pathway in turn, teasing out what happens, and what could be improved. In Table 4.2, changes that have worked for other QI teams are matched with the part of the system on which they have the most impact. These ideas are not meant to be inclusive, but to start a dialogue of what may improve each part of the critical pathway in an organization, and thus improve it overall.

   Changes That Work 

   In Table 4.2: samplechanges that work are linked to the critical pathway for Hypertension Control. 

   Table 4.2: Sample Changes That Work

   Area of Critical Pathway	Patient Changes	Care Team Changes	Health System Changes
   HTN patient presents for care	Educate patients with resources regarding the importance of early hypertensive care and appropriate screening Create expectation that patient must take responsibility to ensure early hypertensive care	Promote BP screenings for patients at every patient encounter Ensure messaging from the care team regarding importance of early hypertensive screening and treatment	Implement standing orders for screening per protocol
   Patient completes intake process	Education for patients on importance of hypertension screening and treatment including guidelines Assess patient beliefs for screenings Assist with appropriate self-management goal setting and strategies to overcome barriers Consider health literacy screening	Culturally competent education for patients to support hypertension screening and treatment Continued education for appropriate screening and risk assessment Providers should agree on guidelines so that care among providers is congruent	Display culturally appropriate posters and brochures in patient areas to encourage patients to talk to providers about HTN screening and treatment Clinical guidelines for HTN risk assessment, appropriate screening and treatment.
   Patient assessment and vital signs completed	Education for patients on importance of hypertension screening and treatment, including guidelines in a cultural-competent manner	Share clinical guidelines in patient-friendly format Providers should agree on guidelines so that care among providers is congruent Document current care plan and share copy with the patient Promote BP screenings for patients at every patient encounter	CMEs for providers that support culturally-competent screening and education supporting appropriate hypertension treatment Clinical guidelines for HTN risk assessment, appropriate screening, and treatment
   Provider assesses hypertension and co-morbidities	Education for patients on importance of hypertension screening and treatment, including guidelines in a cultural competent manner Education on importance of self- management goal setting	Providers should agree on guidelines so that care among providers is congruent Consider health literacy screening Aid patients in self-management goal setting to address potential barriers to care plan Assess co-morbidities	Clinical guidelines for hypertension screening and treatment Providers have continuing educational opportunities to stay current with appropriate interventions (lifestyle and medication)
   A key decision point is provider's determination if: Patient's BP is at goal Patient adheres to lifestyle modifications	Education for patients on importance of controlled BP Assist with appropriate self- management goal setting to support lifestyle modifications	Continued education for appropriate screening and risk assessment Providers should agree on guidelines so that care among providers is congruent	Patient routinely given documentation of current care plan Tools to support hypertension treatment and screening Providers have continuing educational opportunities to stay current with appropriate interventions Display culturally appropriate posters and brochures in patient areas to encourage patients to talk to providers about HTN risk and management
   Is there evidence of end-organ damage?	Education and self-management support for patients experiencing organ damage for setting appropriate BP guidelines	Provider determine if there is end organ damage (i.e., fundoscopy for retinal damage, electrocardiogram for heart damage, etc.) per guidelines Referral to proper specialist if organ damage exists	Clinical guidelines for hypertension screening and treatment Providers have continuing educational opportunities to stay current with appropriate interventions (lifestyle and medication) CMEs for guidelines pertaining to organ damage Automatic referral to specialist per guidelines
   Further management, including lifestyle and medications addressed	Education for patients on importance of controlled BP Assist with appropriate self- management goal setting to support lifestyle modifications	Continued education for appropriate screening and risk assessment Continued self-management support and education for patient Providers should agree on guidelines so that care among providers is congruent Set clear expectations for follow up	Clinical guidelines for hypertension screening and treatment Providers have continuing educational opportunities to stay current with appropriate interventions (lifestyle and medication)
   Develop and reinforce care plan based on assessment	Education on the importance of treatment of controlled blood pressure, including lifestyle modifications and medication compliance Resources for patient support and shared care plan	Help patients to make follow-up appointments Assess current care plan, barriers to following care plan, and collaborate with patient on care plan modifications	Culturally-competent education materials readily available to support care plan planning and reinforcement Providers have continuing education opportunities to stay current with appropriate interventions (lifestyle and medication) Clinical guidelines for hypertension screening and treatment
   Patient is scheduled for follow up	Self-management support between visits as indicated Ensure patients get the relevant information, education, make appointments for follow-up care	Set clear expectations for follow up Assess current care plan, barriers to following care plan, and collaborate with patient on care plan modifications Patient satisfaction survey on navigating system	Ensure patient receives guidance about access to the practice with interim concerns Financial considerations and referral source for low-cost interventions and medications Implement Patient Satisfaction Survey for chronic disease management
   Care Team member contacts patient as medically indicated	Self-management support between visits as indicated Ensure patients get the relevant information, education, and make appointments for follow-up care	Set clear expectations for follow up Assess current care plan, barriers to following care plan, and collaborate with patient on care plan modifications	Ensure patient receives guidance about access to the practice with interim concerns

   This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.

    

   An organization may choose to adapt and refine a tool to assist improvement for the measure, Hypertension Control. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

Earlier in this module, examples are provided of changes (Critical Pathway and Care Model) that have led to improved organizational systems of care and better patient health outcomes. Because every change is not necessarily an improvement, changes must be tested and studied to determine whether the change improves the quality of care. This concept is addressed in detail in the Testing for Improvement module.

It is important that these changes be tested in the context of an organization's staff, current processes, and patients. The goal is that the change results in lasting improvements within an organization.

Organizations commonly use tools to manage change as they work to improve their systems. For a comprehensive discussion of change management, refer to the Testing for Improvement and Redesigning a System of Care to Promote QI modules. Here are a couple of tools that are worth mentioning in the context of this measure:

1. Small tests of change Model for Improvement and PDSA (Plan-Do-Study-Act)
2. Process mapping
   

3. Model for Improvement 

   The Model for Improvement ⁽¹⁷⁾ identifies aim, measure, and change strategies by asking three questions:

   

   Figure: AIM Measure Change

   These questions are followed by the use of learning cycles to plan and test changes in systems and processes. These are referred to as PDSA (Plan-Do-Study-Act) cycles. The PDSA Cycle is a test-and-learning method for discovering effective and efficient ways to change a current process. In Figure 4.3: The PDSA Cycle, the graphic provides a visual of the PDSA process:

   

   Figure 4.3: The PDSA Cycle

   An organization focusing its improvement efforts on Hypertension Control for its patients benefits from implementing PDSAs to test change processes that have an impact on hypertension management. Those organizational processes tested may focus on outreach, operational procedures, or patient education interventions ensuring that patients have timely care. A few examples of such processes relating to Hypertension Control are listed below:

   • What system is in place to provide patients with timely reminders regarding blood pressure screening?
   • What are the assigned roles, duties, and tasks for planned visits to a multidisciplinary care team? Are members of the team cross-trained?
   • Does the patient population understand its specific role in hypertension control, or is there an opportunity for education?
   • Is there an opportunity to educate the community on the importance of hypertension control in a group visit setting?
   • Are there cultural, linguistic, and literacy barriers that the organization may need to address?

   As an organization plans to test a change, it should specify who, what, where, and when so that all staff know their roles clearly. Careful planning results in successful tests of change. Documentation of what happened – the S or study part of the PDSA – is also important. This can help a team to understand the impact of changes to a process as unanticipated consequences may occur.

   The case study may be read in its entirety by clicking here.

   The Case Study: PDSA Cycles in Action

   Tips for Testing Changes

   • Keep the changes small and continue testing.
   • Involve care teams that have a strong interest in improving hypertensive care.
   • Study the results after each change. All changes are not improvements; do not continue testing something that does not work!
   • If stuck, involve others who do the work even if they are not on the improvement team.
   • Make sure that overall aims are improving; changes in one part of a complex system sometimes have an adverse effect in another.

4. Process Mapping

   Process mapping is another valuable tool that an organization focused on improvement often uses. A process map provides a visual diagram of a sequence of events that result in a particular outcome. Many organizations use this tool to evaluate a current process and again when restructuring a process.

   The purpose of process mapping is to use diagramming to understand the current process; i.e., how a process currently works within the organization. By looking at the steps, their sequence, who performs each step, and how efficiently the process works, a team can often visualize opportunities for improvement.

   Process mapping can be used before or in conjunction with a PDSA cycle. Often, mapping out the current process uncovers unwanted variation. In other words, different staff may perform the process differently, or the process is changed on certain days or by specific providers. By looking at the process map, a team may be able to identify gaps and variation in the process that have an impact on Hypertension Control.

   Process mapping, when used effectively, can identify opportunities for improvement, supporting the testing of changes in the current system of care. Additional information, including tools and resources to assist an organization in adapting process mapping as an improvement strategy within its organization, can be found in the Redesigning a System of Care to Promote QI module.

Measures and data are necessary to answer this question. Data is needed to assess and understand the impact of changes designed to meet an organization's specified aim. Measurement is essential in order to be convinced that changes are leading to improvement. Organizations that have experienced successful improvement efforts found that data, when shared with staff and patients outside the core improvement team, led to the spread of improvement strategies, in turn generating interest and excitement in the overall quality improvement process.

Measures are collected prior to beginning the improvement process and continue on a regularly scheduled basis throughout the improvement program. Once an organization reaches its specified goal, frequency of data collection may be reduced. Additional information regarding frequency of data collection, tracking, and analyzing data can be found in the Managing Data for Performance Improvement module.