2014 District of Columbia Million Hearts Meeting

Welcome
2014 District of Columbia
Million Hearts Meeting
Highlighting the ABCS and Local
Strategies for Improved Blood Pressure
Control
All About the Million Hearts
Initiative
Janet S. Wright MD, FACC
Executive Director of Million Hearts
All About Million Hearts:
Preventing a Million Together
Delmarva Foundation for DC and DC Department of Health
Million Hearts Meeting
May 21, 2014
Million Hearts®
Goal: Prevent 1 million heart attacks
and strokes by 2017
• National initiative co-led by CDC and CMS
• In partnership with federal, state, and private
organizations innovating and implementing
• To address the causes of 1.5M events and 800K
deaths a year, $312.6 B in annual health care costs
and lost productivity and major disparities in outcomes
4
Status of the ABCS
People at increased risk
of cardiovascular events
who are taking aspirin
Aspirin
People with hypertension
Blood pressure who have adequately
controlled blood pressure
54%
53%
Cholesterol
People with high cholesterol
who are effectively managed
32%
Smoking
People trying to quit smoking
who get help
22%
Sources: National Ambulatory Medical Care Survey, National Health and
Nutrition Examination Survey, National Health Interview Survey.
Key Components of Million Hearts®
Excelling in the ABCS
Optimizing care
Keeping Us Healthy
Health
Disparities Changing the context
Prioritizing
the ABCS
Health tools
and technology
Innovations in
care delivery
TRANS
FAT
Million Hearts® at 28 Months
66,780
45,787
40M+
96
1M+
2014 Strategic Directions
• Send a Clear Signal
“You can prevent a heart attack or stroke. Do 1, 2, 3…”
•
•
•
•
The public and patients
Healthcare professionals and systems
Public health professionals and communities
Payers and purchasers
Target Audiences
• Measure and Report Progress
• Reach. Results. December 2016?
• Find Those at Risk for Heart attack and Stroke
– Detect. Connect. Control.
– Address Aspirin use, Cholesterol, and Smoking
Key Components of Million Hearts®
Excelling in the ABCS
Optimizing care
Prioritizing
the ABCS
Health tools
and technology
Innovations in
care delivery
Keeping Us Healthy
Health
Disparities Changing the context
Changing the Context:
Cigarette Excise Taxes
Total = $6.86
Total = $5.26
Total = $4.64
Total = $3.39
Total = $1.58
10
Decline in Smoking in New York City, 2002–2010
450,000 Fewer Smokers
NYC & NYS
tax increases
Smoke-free
workplaces
Free patch
programs
start
3-yr average
3-yr average
Adults (%)
3-yr average
Hard-hitting
media
campaigns
NYS
Federal
tax
tax
increase
increase
NYS
tax
increase
New York City Community Health Survey.
What Can You Do Today?
•
•
•
•
•
•
Smoke free campus
Describe quitting as a process, a practice
Offer behavioral counseling and pharmacotherapy at no- or low-cost to
employees
Embed EHR reminders to provide cessation support
Select and report on smoking cessation measure: NQF 0028/PQRS 226
Use these resources:
– National Network of Tobacco Cessation Quitline: Call 1-800-QUITNOW (1-800-7848669). TTY users call 1-800-332-8615.
– CDC information on smoking & tobacco use
– NCI's tobacco & cancer information resources
– Smokefree.gov
– National Institutes of Health
– American Lung Association—Tobacco Control Advocacy
Key Components of Million Hearts®
Excelling in the ABCS
Optimizing care
Prioritizing
the ABCS
Health tools
and technology
Innovations in
care delivery
Keeping Us Healthy
Health
Disparities Changing the context
U.S. Dietary Guidelines for Americans
Recommendations for Sodium Intake

Current average intake in adults is ~ 3,400mg/day

2,300 mg/day for general population

1,500 mg/day for specific populations

≥ 51 years

African Americans

High blood pressure

Diabetes

Chronic kidney disease
~1/2 U.S. population and
the majority of adults
44% of U.S. Sodium Intake
Comes from Ten Types of Foods
Rank
Food Types
%
1
Bread and rolls
7.4
2
Cold cuts and cured meats
5.1
3
Pizza
4.9
4
Poultry
4.5
5
6
7
.
More than 75% of the sodium in our
Soups
food is already
there and mostly
invisible in processed
and restaurant
Sandwiches
foods.
4.3
4.0
Cheese
3.8
8
Pasta mixed dishes
3.3
9
Meat mixed dishes
3.2
10
Savory snacks
3.1
CDC, MMWR;2012;61:92-98
What Can You Do Today?
•
•
•
•
•
Start the conversation about your food environment
Establish or update your Comprehensive Food Policy
Modify the Built Environment
Educate
Use these resources:
• HHS and GSA Health and Sustainability Guidelines for
Federal Concessions and Vending Operations
• Dietary Guidelines for Americans
• www.cdc.gov/salt/resources
• https://www.cspinet.org/nutritionpolicy/foodstandards.html
Key Components of Million Hearts®
Excelling in the ABCS
Optimizing care
Keeping Us Healthy
Health
Disparities Changing the context
Prioritizing
the ABCS
Health tools
and technology
Innovations in
care delivery
TRANS
FAT
Keeping Us Healthy
Changing the Context: trans fat
Eliminating trans fat in the American diet could prevent
20,000 heart attacks, 7,000 deaths—every year
• Citing new scientific evidence and findings from
expert scientific panels, FDA takes first step to
eliminate trans fat from processed foods*
• Federal Register comment period ended Jan. 2014
*FDA. Tentative Determination Regarding Partially Hydrogenated Oils; Request for Comments and
for Scientific Data and Information. Federal Register Volume 78, Issue 217 (November 8, 2013)
18
Getting to a Million
2009-2010
Measure
Value
2017 Target
Clinical
target
Aspirin for those at risk
54%
65%
70%
Blood pressure control
53%
65%
70%
Cholesterol management
32%
65%
70%
Smoking cessation
22%
65%
70%
Smoking prevalence
21%
19%
Sodium reduction
~ 3.5 g/day
20%
reduction
Trans fat reduction
~ 1% of calories
50%
reduction
Intervention
Sources: National Ambulatory Medical Care Survey, National Hospital Ambulatory Care Survey,
National Health and Nutrition Examination Survey, National Health Interview Survey,
Fewer than Half of Americans with
Hypertension are Under Control
67 MILLION
ADULTS WITH HYPERTENSION (30.4%)
(35.8 M)
CDC. MMWR. 2012;61(35):703–9.
Awareness and Treatment among the 36M
with Uncontrolled Hypertension
36 MILLION
ADULTS WITH UNCONTROLLED
HYPERTENSION
M
M
M
CDC. MMWR. 2012;61(35):703–9.
The 36 M People with Uncontrolled
Hypertension
Yes
No
Usual source of care
Yes
No
Health insurance
CDC. MMWR. 2012;61(35):703–9.
None
1
≥2
No. times received
care in past year
Stroke and Hypertension
• Stroke mortality in the United States has dropped
across both genders, all races and all age groups
• Each additional 20 mmHg (SBP) and 10 mmHg
(DBP) above 115/75 was associated with a 2 fold
increase in stroke death rates
• Hypertension is responsible for the largest number
of CV and stroke deaths in the U.S.
Hypertension Guidance
Take-Aways
•
•
•
•
•
Sustained elevations in blood pressure are deleterious, even mild
reductions are beneficial, and too many people are still uncontrolled
The differences in treatment goals between JNC 7 and the 2014 guidance
are minor compared to the burden of disease caused by uncontrolled
hypertension
Treatment goals should be individualized based on patient risk, tolerance,
and likelihood of benefit. National and international experts recognize this
principle but differ in the ages at which specific treatment goals apply.
National guidelines for hypertension will be released in 2015 from a group of
professional societies in collaboration with the National Heart, Lung and
Blood Institute
The performance measure for BP control remains <140/90 for PQRS, MU.
Translate and
Diffuse
Knowledge
Million Hearts® Webinar Series
Nurse Practitioners and Million Hearts®
Partnering to Achieve Blood Pressure Control
Create and Align Incentives
1. Recognize achievement and improvement
2. Reimburse and reward for high performance
3. Reduce the “hassle factor” by making the most
impactful thing the easy thing
 PQRS, EHR Incentive program, Value-Modifier
 CMMI’s Comprehensive Primary Care, State
Innovation Models, and ACOs
 Hypertension Control Champions
2013 Million Hearts®
Hypertension Control Champions
•
•
•
•
•
•
Dr. Luz Ares, Broadway Internal Medicine; Queens, NY
Cheshire Medical Center/Dartmouth-Hitchcock; Keene, NH
9 Champions
Dr. Jen Brull; Plainville,
Kansas
Solo
to 70,000 Clinicians
8.3M People
Dr. Nilesh V. Patel; Audubon,
PA
3.4MCenter;
with Hypertension
Pawhuska Indian Health
Pawhuska, OK
~81% Control Rate
Kaiser Permanente Northern California
• River Falls Medical Clinic; River Falls, WI
• ThedaCare; Appleton, WI
• Veterans Health Administration
Broadway Internal Medicine; Queens, NY
Champions’ Secrets to Success
in Hypertension Control
•
•
•
•
•
Find, grow, crown an in-house champion
Take action to improve medication adherence
Use your EHR as a tool for quality
Deploy a team—working off the same playbook
Teach self-monitoring of blood pressure and
provide clinical support
• Stay in touch between visits
Activated Public Sector Partners
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Administration on Community Living
Agency for Healthcare Research and Quality
Environmental Protection Agency
Federal Occupational Health
Food and Drug Administration
Health Resources and Services Administration
Indian Health Service
National Heart, Lung, and Blood Institute
National Institute for Neurological Diseases
Office of the Assistant Secretary for Health
Office of the National Coordinator for Health Information Technology
Office of Personnel Management
Substance Abuse and Mental Health Services Administration
U.S. Department of Veterans Affairs
Activated Private Sector Partners
• Academy of Nutrition and
•
Dietetics
•
• Aetna
•
• Alliance for Patient Medication •
Safety
•
• America’s Health Insurance
Plans
•
• American Academy of Family •
Practitioners
•
• American Association of Nurse •
Practitioners
• American College of Cardiology •
• American College of Physicians
• American Heart Association
•
• American Medical Association •
• American Medical Group
•
Foundation
•
• American Nurses Association
• American Pharmacists’
•
Association and Foundation
• Arkansas Dept of Health
•
• Asso of Black Cardiologists
•
• Asso of Public Health Nurses
Be There San Diego
Blue Cross Blue Shield Asso
Cherokee Nation Health Svcs
Commonwealth of Virginia
Georgetown University School
of Medicine
HealthPartners
Humana
Kaiser Permanente
LDI Ctr for Health Incentives &
Behavioral Economics, UPenn
Maryland Dept of Health and
Mental Hygiene
Medstar Health System
Mended Hearts
Men’s Health Network
Minnesota Heart Health
Program
National Alliance of State
Pharmacy Associations
National Association of NPs in
Women’s Health
National Committee for Quality
Assurance
• National Community
Pharmacists Association
• National Consumers League
• National Forum for Heart
Disease and Stroke Prevention
• National Lipid Association
Foundation
• New Mexico Heart Institute
• NY State Department of Health
• Ohio State University
• Pennsylvania Dept of Health
• Presbyterian Health Care Svcs
• Prescribe Wellness
• Preventive Cardiovascular
Nurses Association
• Society for Women’s Health
Research
• SureScripts
• UnitedHealthcare
• University of Maryland School
of Pharmacy
• Walgreens
• Walk with a Doc
• WomenHeart
• YMCA of America
100 Congregations for Million Hearts®
The Commitment
In addition to designating a Million Hearts® Advocate we
will focus on two or more of these actions for the next year
and share our progress:
• Deliver pulpit and other leadership messages
• Distribute wallet cards and journals for recording blood
pressure readings
• Promote and use the Heart Health Mobile app
• Facilitate connections with local health professionals
and community resources
Measure and Report Systematically
1.
2.
3.
4.
Refine and align measures
Facilitate reporting
Monitor and evaluate
Improve data access and surveillance systems
 HHS and CMS efforts to “liberate the data”
 CDC and CMS experts digging into Part D data
 Measure alignment across public and private
programs
Impactful Measures in Impactful Programs, 2011
Quality Measure
PQRS/NQF
HRSA
PQRS CV
Meaningfu Unifor
CMMI Comp
Prevention PQRS
Medicaid
l
m
VA
Primary
ACOs
Measures GPRO
Use
Data
Care
Group
System
Aspirin
S1
optional
204/0068
BP Screening
BP Control
236/0018

S1
optional


Cholesterol
Control
Cholesterol
Control in
Diabetes 2/0064
S1 opt

S1 opt

Cholesterol
Control in IVD
0075
January 2011
Impactful Measures in Impactful Programs, 2013
Quality Measure
PQRS/NQF
Medicaid
Aspirin
St 1 opt
St 2 opt
204/0068
BP Screening
236/0018
Cholesterol
316
Cholesterol
Control in
Diabetes 2/0064
Cholesterol
Control in IVD
241/0075
Asmoking
of July 2013
S
HRSA
Uniform
Data
System
VA


PQRS CV
Prevention PQRS
Measures GPRO
Group
CMMI
Comp
Primary
Care






St 1 opt
St 2 opt




St 1 opt
St 2 opt




St 1 opt
St 2 core

ACOs
#30

317
BP Control
Control
Meaningfu
l
Use
#21
#28
St 2 opt
#29
Innovate and Implement for
Population Health
1. Deploy team members--including health IT--effectively
2. Focus community action on MH key areas: ABCS, smoke
exposure, sodium and trans-fat reduction
3. Build community-clinical linkages
4. Facilitate patient self-management
 ONC, CDC, others working on clinical decision support
 CDC-ASTHO partners improving BP control
 CMMI HealthCare Innovations Awards I and II
 Protocols Across America project
Detect.Connect.Control in DC
Protocol as Team Playbook
Protocols, a key to effective treatment
Evidence-based, standardized approach
• Reduces non-clinical
variation
• Clarifies treatment
options + titration
intervals – streamlines
selection of preferred
medications
• Engages staff in timely
and efficient follow-up
• Facilitates QI efforts
• When embedded in EHRs,
serves as clinical decision
support tool at point of care
• Sends a strong signal to
clinical staff –and to patients
and families--that
hypertension control is a
health priority
Research:
Understanding What Works and Why
1. Identify gaps
2. Fund research to improve outcomes in CVD
3. Conduct research
 PCORI, AHRQ, NHLBI, NINDS, among others
 Partners….
NorthShore Undiagnosed Hypertension
Project
•
•
•
•
•
Set of algorithms run in the EHR background
Ambulatory BP monitor readings in follow-up
Interdisciplinary team working to control BP
Non-disruptive, actionable alerts to treating provider
Eliminating hypertensive patients “hiding in plain
sight”
Kaiser Permanente Northern California
Implementation Timeline
2000
HTN
registry
developed
2002
Performance
measures
distributed
1995
Guideline
created;
updated
every 2 yrs
1995
2005
Single pill
combination
promoted
2007
Non-MD
BP visits
Successful
practices
disseminated
1997
1999
2001
2003
2005
2007
Kaiser Permanente Northern California
Heart Attack Rates Declining
Jaffe M. The Permanente Medical Group, Inc.
What Can You Do Today and Tomorrow?


Send a clear signal that heart attacks and strokes are
preventable with good habits and good care
Measure and report progress
 Adopt and excel in the ABCS

Find those at risk for heart attack and stroke
 Ensure that community-based resources are identified and
activated to help people achieve and maintain control
 Deploy teams, technologies, and processes
• Nurses, pharmacists, dieticians, community health workers, peers
• “Remote control” of blood pressure monitoring
• Health IT: registries, reminders, and reasons
• Standardized treatment approaches, aka protocols
Join Us
Subscribe—and Contribute to-- the E-Update
Become a Partner
Be One in a Million Hearts®
millionhearts.hhs.gov
Extra Slides on Sodium Policy and 2013
Cholesterol Guidelines
Establish a Comprehensive Food Policy
•
•
•
•
•
Establish purchasing requirements with nutrition standards
for foods served in the cafeteria, vending machines, café
carts, gift shops, and franchises
Ensure that menu items are “heart healthy” & “low sodium
Base purchasing requirements on nutrition standards as a
component to accept or reject a bid for food service
Offer (only) healthful, lower sodium food at meetings and
work-shops hosted by or at your hospital
Case Example
• Good Shepherd Health Care System in Hermiston, Oregon,
banned potato chips in favor of carrots and replaced beef with
antibiotic- and hormone-free bison
Modify the Built Environment
•
•
•
•
•
Place lower sodium, more healthful options near the
point of purchase
Replace vending machine foods with more healthful
choices, as pioneered by Cleveland Clinic
Use pricing strategies as incentives for purchasing
healthful foods.
Use traffic lights to identify foods that are considered
healthy and foods that are high in sodium.
Case Example:
• Stillwater Medical Center, OK priced “healthy” foods 20% lower
and prices for “unhealthy” foods 20% higher. Sales data were
reportedly higher for the more healthful foods.
Educate
•
Employees
• Provide nutrition and sodium education during new employee
orientations
• Encourage staff to distribute sodium information when dispensing a
patients’ blood pressure medication.
•
Employees & Visitors
• Provide nutrition information such as table tents, menu labeling,
brochures
• Provide educational materials for families about sodium’s impact
on blood pressure and on the hidden sources of sodium
•
Patients
• Provide in-patient education as a part of discharge planning.
• Refer patients for nutritional counseling after discharge.
Recommendations for Statin Therapy in
ASCVD Prevention
High-intensity statin
Age < 75
(Daily dose lowers LDL–C by
approx. ≥50% )
Age > 75 OR
not a candidate
for highintensity statin
Moderate-intensity statin
Clinical
ASCVD
LDL-C
> 190
mg/dL
(Daily dose lowers LDL–C by
approx. 30% to <50% )
High-intensity statin
(moderate-intensity statin if
not a candidate for highintensity statin)
Adapted from the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. E-Published on November
Recommendations for Statin Therapy in
ASCVD Prevention
Diabetes
Type 1 or 2
Age 40-75 y
Moderate-intensity statin
(Daily dose lowers LDL–C by
approx. 30% to <50% )
Estimated 10-y ASCD risk
> 7.5%
High-intensity statin
(Daily dose lowers LDL–C by
approx. ≥50% )
≥7.5%
estimated
10 y
ASCVD
risk and
age 40-75 y
Moderate-to-high
intensity statin
Adapted from the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. E-Published on November
12, 2013, available at [http://content.onlinejacc.org/article.aspx?doi=10.1016/j.jacc.2013.11.002]
Bridging Guidelines
and Practices
Lawrence J. Fine, MD, DrPH, FAHA,
National Heart Lung and Blood
Institute, National
Unpacking Recent Hypertension
Guidelines
Lawrence J. Fine, MD, DrPH, FAHA
Division of Cardiovascular Sciences
NHLBI/NIH
May 7, 2014
Disclosures: Member of Panel Appointed
to the Eighth Joint National Committee
(JNC 8)
53
Million Heart
to build on
TheCampaign
Millionwants
Heart
the accelerating progress of the last
Campaign
is building on
twenty
years
the accelerating
progress of the last
twenty years
54
“Getting warm …. warmer.”
55
“Avoidable” Deaths from Heart Disease,
Stroke, and Hypertensive Disease – United
States, 2001 -2010
MMWR September 6, 2013
 Look at CVD mortality for those < 75 years
old
 Nearly one fourth of all CVD death avoidable
 56% of the avoidable deaths in those < 65 (
important target for primary prevention )
 Some of these ‘avoidable’ deaths are likely
due to lack of preventive health care or timely
and effective medical care.
56
Number of Avoidable Deaths from CVD
deaths – United States, 2001 -2010
Age
CVD
Groups Death
s in
2001
35-54
46,426
55-64
65-74
CVD
Death
s in
2010
43,884
Percent
Decline in
Death Rate
(p < .05)
-6%
61,105 65,680 -27%
117,66 87,741 -37%
2
MMWR 9/26/2013
57
Schieb LJ
Rates of Avoidable Deaths Data Illustrates
Murray’s Eight Americas: new
perspectives on U.S. health disparities.
Race/Ethnic 2001
ity and sex Rates
per
100,000
Asian
36
Females
White Men 112
2010 (% Decline
over 10 years p
Hispanic
Men
63 (-28%)
58
93
< .05)
Asian men
47
22 (-39%)
81 (-28%)
Disentangling Complexity is Challenging – Why
did CVD decrease and how can we make
additional progress ?
59 http://www.smallmanart.com/2012/07/05/disentangling-complexity.html - ©
Stefano Masini 2012
A Partial Answer: Trends in LDL 1988-2010
Age Specific LDL mg/dL in Adults
60-69. Carroll et al. 2012 JAMA
160
150
140
130
Wom
en
146
139
133
122
120
110
108
100
1988-1994
60
1999-2002
2007-2010
Another Contributor with a Different Secular
Pattern
Age Adjusted SBP in Adults 60 +
Yrs. 1999 to 2010 NHANES Guo et al.
145
2012 JACC
140
135
130
125
61
No
Change
1988 to
2000
2002
1999
10
mm
Delta
2004
2006
2008
2010
Disentangling Complexity is Challenging – Many
new guidelines?
62 http://www.smallmanart.com/2012/07/05/disentangling-complexity.html - ©
Stefano Masini 2012
Four New Guidelines
 2014 Evidence-Based Guideline for the
Management of High Blood Pressure in Adults:
Report from the Panel Members Appointed to
the Eighth Joint National Committee (JNC 8)
 American Society of Hypertension and the
International Society of Hypertension Clinical
Practice Guidelines for the Management of
Hypertension in the Community
 2013 European Society of
Hypertension/European Society of Cardiology
Guidelines
63
Four New Guidelines
 2013 Canadian Hypertension Guidelines
 Each set of these guidelines was
independently developed. They used
different methodology and criteria for
reaching their conclusions and varied in how
comprehensive their recommendations were.
All acknowledged that many keys questions
remained unanswered and called for greater
research
64
Systolic Blood Pressure Treatment Goals
and Thresholds
 Areas of agreement 140/90 for both Goal
and Threshold
 Individuals younger than 60
 Individuals with diabetes
 Individuals with chronic kidney disease
(CKD) without significant proteinuria
The JAMA Report in December 2013
 2014 Evidence-Based Guideline for the Management of
High Blood Pressure in Adults Report From the Panel
Members Appointed to the Eighth Joint National
Committee (JNC 8)
 Paul A. James, MD1; Suzanne Oparil, MD2; Barry
L. Carter, PharmD1; William C. Cushman, MD3;
Cheryl Dennison-Himmelfarb, RN, ANP, PhD4;
Joel Handler, MD5; Daniel T. Lackland, DrPH6; Michael
L. LeFevre, MD, MSPH7; Thomas D. MacKenzie, MD,
MSPH8; Olugbenga Ogedegbe, MD, MPH, MS9; Sidney
C. Smith Jr, MD10; Laura P. Svetkey, MD, MHS11; Sandra
J. Taler, MD12; Raymond R. Townsend, MD13; Jackson
T. Wright Jr, MD, PhD14; Andrew S. Narva, MD15;
Eduardo Ortiz, MD, MPH16,17
66
2014 Evidence-Based Guideline for the Management of High
Blood Pressure in Adults: Report From the Panel Members
Appointed to the Eighth Joint National Committee (JNC 8)
Guideline Goal BP and Initial Drug Therapy for Adults With Hypertension
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Date 67
of download: 2/11/2014
Copyright © 2014 American Medical
Association. All rights reserved.
Recommendation 1 and Corollary
Recommendation
 In the general population aged ≥60
years, initiate pharmacologic treatment
to lower blood pressure (BP) at
systolic blood pressure (SBP) ≥150
mm Hg or diastolic blood pressure
(DBP) ≥90 mm Hg and treat to a goal
SBP <150 mm Hg and goal DBP <90
mm Hg. (Strong Recommendation –
Grade A)
Recommendation 1’s Corollary
Recommendation
 Corollary Recommendation - … if
pharmacologic treatment for high BP
results in lower achieved SBP (eg,
<140 mm Hg) and treatment is well
tolerated and without adverse effects
on health or quality of life, treatment
does not need to be adjusted. (Expert
Opinion – Grade E)
69
HYVET - Blood Pressure, Measured by
Study Group
Beckett NS et al. N Engl J Med 2008;358:1887-1898
70
Main Fatal and Nonfatal End Points
Beckett NS et al. N Engl J Med 2008;358:1887-1898
71
Adverse Effects of Diuretic and ACEI
Combination in HYVET
72
Other views
http://www.ash- us.org/documents/ASH_ISHGuidelines_2013.pdf
73
Where ASH and the JAMA JNC paper
agreed.
 “ The treatment goal for systolic blood
pressure is usually <140 mm Hg and
for diastolic blood pressure <90 mm
Hg. In the past, guidelines have
recommended treatment values of
<130/80 mm Hg for patients with
diabetes, chronic kidney disease, and
coronary artery disease. However,
http://www.ash- us.org/documents/ASH_ISHevidence
to support this lower target
Guidelines_2013.pdf
74
Where do ASH and the JAMA JNC 8 diverge on
SBP Thresholds and goals?
 For patients older than 80 years, the
suggested
threshold for starting treatment is at levels
≥150/
90 mm Hg. Thus, the target of treatment
should be
<140/90 mm Hg for most patients but
<150/
90
mm Hg for older patients (unless these
http://www.ash- us.org/documents/ASH_ISHGuidelines_2013.pdf
patients
75
Treatment Goals and Thresholds in Older
individuals
 Biggest area of diversion is between 60 and
79 years old
 There is more general agreement for those
for individuals 80 and over, particularly if they
are fragile, that the treatment goal should be
seriously considered 150/90 rather than
140/90
76
Treatment Goals and Thresholds in Older
individuals
 This includes the expert opinion that if an
individual is doing well on treatment there is
no compelling reason to reduce the intensity
of treatment at a specific age.
 Fragile not defined – consider fall risk,
multiple medications, and CKD
 Other guidelines Canadian, UK and
ESH/ESC all support the 150/90 goal for
those 80 and older.
Initial Drug Choices – General Population
and Diabetes
JNC 8 Panel
ASH
 Nonblack: Thiazide-type
diuretic, ACEI, ARB, or CCB
 Nonblack and ≥ 𝟔𝟎 :
Thiazide diuretic, or CCB (
ACEI or ARB also ok)
 Nonblack and < 𝟔𝟎: ACEI or
ARB
 Black Patients: Thiazidetype diuretic, or CCB
 Patients with Diabetes:
ACEI or ARB, ( in Blacks:
Thiazide and CCB also ok)
 Black Patients - Thiazidetype diuretic, or CCB
 Patients with Diabetes:
Thiazide-type diuretic,
ACEI, ARB, or CCB
 Both Agree on ACEI and
ARB for CKD patients
78
Minority View from JNC 8 Panel members
on only one recommendation
 Wright was frank: "This
article is not intended as an
attack on the 2014
hypertension guidelines. . . .
The purpose of
this Annals commentary
was to clarify the rationale
behind the defense of
keeping the 140-mm-Hg
target, rather than raising it
to 150 mm Hg”.
 Lot of dialogue and mutual
respect on the Panel
79
Differing perspectives on whether there was
evidence of benefits
Majority Perspective
 HYVET, Syst-Eur and
SHEP showed benefit but
had average SBP in the
active arm was between
143 and 150 mm Hg
 Only two other studies
goal trials (JATOS and
VALISH) while having
limitations provided no
evidence of benefit of
145 vs. 135.
80
Minority Perspective
 Evidence from trials and
observational studies that
the panel did not use as
part of its review supports
the lower goal, especially
in high-risk patients.
 Two large meta-analysis
supported the < 140 goal
 Inconsistency on lower
goal ok for Diabetes but
not other high risk groups
These differing perspectives were reflected
within the Appointed JNC 8 Panel
Majority Perspective

81
“No. 1, it's going to simplify the
goals (of treatment because) there
are only two goals to remember. No.
2, I do think a lot of physicians who
take care of the elderly have been
concerned over the years about the
potential for causing harm by
overtreating blood pressure." It's
certainly not uncommon for elderly
patients to become dizzy on
standing because of the
antihypertensive medication or
medications they take. Such
patients, James noted, are at an
increased risk for falls and their
sequelae”.
Minority Perspective
 What is the trial
evidence of increase
risk of serious
adverse events with
treatment to < 140
mg Hg.
 JATOS, VALISH,
and SPS3 all
concluded that lower
goal was safe.
One of the Reasons for Differing
Conclusions
Table 2 Trials Comparing SBP < 140 mmHg vs. Higher
SBP Goal
TRIAL (N)
TOTAL
ENDPTS
JATOS(21)
(n=4,418)
N= 172
VALISH(17)
(N = 3,260)
82
FEVER(16)
N= 99
N = 575
COMPOSITE
CVD
STROKE
Rate per 1000 Rate per 1000
py: 22.6 vs
py: 13.7 vs.
22.7
12.9 P=0.77
P=0.99
HR: 0.89
HR: 0.68
p = 0.383
p = 0.237
HR: 0.73
HR: 0.73
Possible Consequences of the Higher Goal
 Increasing the systolic BP target in those 60
years or older will have the effect of reducing the
intensity of antihypertensive treatment among
patients already being treated, among them a
large population with established CVD or at high
risk for CVD (including African Americans and
patients with multiple CVD risk factors other than
chronic kidney disease).
 Raising the target may have the unintended
effect of reversing decades of declining CVD
rates, especially stroke mortality.
83
US CVD Death Rates for Individuals < and >
than 65 years
Condition
(Cause of
death by
underlying
Cause)
Coronar
y
Disease
Coronar
y
Disease
Stroke
84Stroke
1989-1998 1999-2010
Average
Average
Age < 65 1999-2010
Yearly
annual %
annual %
or
Average
change in change in
≥ 65 years
Death Rate
ageageadjusted
per 100,000 adjusted
death rates death rates
< 65
30
-3.6
-3.4
≥ 65
1038
-2.7
-5.6
< 65
≥ 65
7
356
-1.3
-0.9
-2.3
-5.3
Adverse Effects in Goal Trials
HYVET, JATOS, and VALISH
show not increases while
SHEP did
SPS3
Systolic Blood Pressure by Treatment
Groups
•At 1 yr follow-up average SBPs were 138 vs. 127 mm Hg
•Last observed visit, average SBP difference between groups was 11 mm Hg
SPS 3 Serious adverse related to
hypotension
SPS 3 Side effects potentially related to BP
management
These differing perspectives were reflected
within the Appointed JNC 8 Panel
Majority Perspective
Minority Perspective
 “ No. 2, I do think a lot of
physicians who take care of
the elderly have been
concerned over the years
about the potential for causing
harm by overtreating blood
pressure." It's certainly not
uncommon for elderly patients
to become dizzy on standing
because of the
antihypertensive medication or
medications they take. Such
patients, James noted, are at
an increased risk for falls and
their sequelae”.
 What is the trial
evidence of increase
risk of serious
adverse events with
treatment to < 140
mg Hg.
 JATOS, VALISH,
and SPS3 all
concluded that lower
goal was safe.
89
International Symbol for Don’t
Rock the Boat
90
After the JAMA publication
American Heart Association stays with JNC 7
 The American Heart Association and the American College
of Cardiology released four cardiovascular treatment
guidelines for healthcare providers in November, and next
year they will be updating their high blood pressure
guidelines as well. The new report that was published in
JAMA,… will be taken into consideration for those
guidelines, which will be the national standard for treating
hypertension.
Until then, the AHA/ACC recognize the most recent
hypertension guidelines, published in 2004 by the Joint
National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure, as the national
standard.
91
W
What will resolve the
controversy ?
w
92
“More data”
Jackson Wright
Thank You (Incomplete List) although what I
said may not reflect their views.
Jackson Wright
Daniel Lackland
Gbenga Ogedeghe
Cheryl Dennison
Michael Mussolino
Joni Snyder
Paul Sorlie
Stefano Masini
Other Member of the JNC 8
Panel
Authors of the articles that I
used.
93
94
Creating Networking
Opportunities
(BREAK)
Please return in 10 minutes
95
Sharing Resources for
Hypertension Detection
and Control
Kendra Gaskins Director of Measure
Up/Pressure Down™ Campaign &
Chronic Care Initiatives, American
Medical Group Association
96
What is AMGA?
The American Medical Group Association supports its
members in enhancing population health and
care for patients through integrated systems of care.
National Reach
 AMGA’s 430+
medical groups
 Treat 1 in 3
Americans
 Represent 150,000
physicians
 Deliver health care
to 130 million
patients in 49 states
 Average group size
is 330 MDs
Chronic Care Challenge

Multi-year initiative to address
the most pressing chronic
conditions in the nation

Harnesses best practices
identified through AMGF’s
Learning Collaboratives

First national campaign:
Measure Up/Pressure Down®
Why High Blood Pressure?
68 million adults have high
blood pressure, meaning that
millions of Americans are at
increased risk for heart
disease and stroke—two of
the leading causes of death in
the U.S.
According to local data, prevalence rates
in the DC area are as high as 55 percent
Campaign Goals
Secondary
Primary
Mobilize medical groups to achieve
measurable improvements in high
blood pressure prevention, detection,
and control


80% of patients at goal by 2016
50% of AMGA membership adopt
at least one campaign plank
Engage and empower patients to
actively manage their health


Raise awareness of the dangers of
uncontrolled high blood pressure
Encourage consumers to obtain BP
screenings, partner with
healthcare provider, make lifestyle
changes, etc.
Participating Medical Groups
(Delivering care to more than 42 million patients)
Adirondack Internal Medicine &
Pediatrics, P.C.
Advocate Medical Group
Advocate Physician Partners
Alegent Health Clinic
Allina Health
Arch Health Partners
Aurora Health Care
Austin Diagnostic Clinic, P.A.
Austin Regional Clinic, P.A.
Baptist Health Medical Group
Baptist Memorial Medical Group
Baylor Health Care System/Health
Provider Network
Bend Memorial Clinic
Benefis Medical Group
Billings Clinic
Brown & Toland Physicians
Carilion Clinic
Carolinas Healthcare System
Catholic Health Initiatives
Central Utah Clinic
Centura Health Physician Group
Christie Clinic, LLC
Clackamas County Health Centers
Cleveland Clinic
Coastal Carolina Health Care PA
Colorado Springs Health Partners
Community Clinic, Inc
Community of Hope
Community Physician's of Indiana
Cornerstone Health Care
Crystal Run Healthcare
Dartmouth-Hitchcock Clinic
Deaconess Clinic
Dean Health System
Essentia Health
Fairview Medical Group
Florida Medical Clinic, P.A.
Geisinger Health System
Group Health Cooperative of South
Central Wisconsin
Hartford HealthCare Medical Group
Hattiesburg Clinic, P.A.
Hawaii Pacific Health (Straub Clinic and
Hospital and Kauai Medical Group)
Health First Physicians/MIMA
HealthCare Partners
HealthPartners
HealthPoint Medical Group
Henry Ford Medical Group
Heritage Valley Medical Group
Holston
Hospital Sisters Health System Medical
Group
INOVA
Intermountain Healthcare
Iowa Clinic
Kelsey-Seybold Clinic
Kish Health Physician Group
Lahey Clinic
Lakeshore Clinic
Lakeshore Health Partners
Maitland Family Practice
Mankato Clinic
Mayo Clinic Health System
Medical Associates Clinic, P.C.
Medical Associates, PLC
Medstar
Mercy Clinic Northwest Arkansas
Mercy Clinic-East Communities
Mercy Des Moines
Meridian Practice Institute
Meritage Medical Network (MarinSonoma IPA)
Mid- Hudson Medical Group
Mid-Atlantic Permanente Medical Group
Mount Kisco Medical Group
Mountain View Medical Group
NEA Baptist Clinic
New West Physicians
North Mississippi Medical Clinics, Inc.
North Texas Specialty Physicians (Medical
Clinic of N TX)
NorthShore University HealthSystem
Medical Group
Northwest Primary Care Group PC
Novant Medical Group
Ochsner Health System
Oregon Medical Group, P.C.
OU Physicians
Pacific Medical Centers
Palo Alto Foundation Medical Group
Park Nicollet Health Services
Parkview Physicians' Group
PeaceHealth
Piedmont Healthcare
Piedmont HealthCare, P.A.
Portland IPA
Prevea Health Services
PriMed Physicians
ProHealth Physicians
Puget Sound Family Physicians
Quincy Medical Group
Refuah Health Center
Reliant Medical Group
Rio Grande Medicine
Riverside Medical Clinic
Riverside Medical Group
Rockford Health Physicians
Rockwood Clinic
Sacramento Family Medical Centers
Scripps Coastal Medical Group
Scripps Medical Foundation
Sentara Medical Group
Shannon Medical Center
Sharp Rees-Stealy Medical Group
Shaw Center for Women's Health
Springfield Clinic
St Anthony's Physician Services
St. Luke's Physician Group
State of Franklin Healthcare Associates, PLLC
Summa Health System
Summit Medical Group
Susquehanna Health Medical Group
Sutter Independent Physicians
Sutter Medical Group
Sutter North Medical Group
Swedish American Medical Group
The Baton Rouge Clinic
The Everett Clinic
The Jackson Clinic, P.A.
The Permanente Medical Group
The Polyclinic
The Stern Cardiovascular Foundation
ThedaCare Physicians
Triad HealthCare Network/Cone Health
TriHealth Practices
UnityPoint Health (Iowa Health System)
University of North Texas Health Science
Center
University of Utah Community Clinics
Upper Valley Family Care
Warren Clinic/Saint Francis Health System
Washington Township Medical Foundation
Watson Clinic LLP
Weill Cornell Physician Organization
Wellmont Medical Associates
Wellstar Cardiovascular Medicine
Wenatchee Valley Medical Center
Westchester Health Associates
Western Montana Clinic
Westmed Medical Group
Wheaton Franciscan Medical Group
Wilmington Health
Campaign Sponsors
Campaign Partners
Campaign Planks
Planks in Practice
Here is how some of our medical groups are taking on the Measure Up/Pressure Down®
challenge:
Plank 1: Direct Care Staff Trained in Accurate Blood Pressure Measurement
Colorado Springs Health Partners, P.C.
Inventoried its exam rooms to address the problem of inaccurate blood pressure
screening. Staff who received hypertension competency training based on this plank
discovered that many blood pressure units were in less-than-ideal locations. To resolve
this issue, they moved all wall units in the exam rooms next to chairs so patients could sit
with their feet flat on the floor and cords wouldn’t get stretched.
Planks in Practice
Plank 4: All Patients Not at Goal or With New Rx
Seen Within 30 Days
Kaiser Permanente
All medical centers developed a medical assistant
follow-up visit, typically scheduled 2-4 weeks
after medication adjustment. The medical
assistant measured the blood pressure and
informed the primary care physician who
directed treatment decisions and follow-up
planning. Medical assistants were trained using
standardized materials and blood pressure
competency assessments. Control rates improved
from 44% to 87%, and their results were
published in JAMA.
Planks in Practice
Plank 5: Prevention, Engagement, and SelfManagement Program in Place
Billings Clinic
At each appointment, patients receive a “Your
Blood Pressure Report Card” with a rich trove of
motivational data, such as:
• Recent blood pressure readings, arm
circumference, and weight measurements
from EHRs
• Background on risk factors such as preexisting heart, kidney, and stroke conditions
• Goals in areas such as weight loss
• Tips for working toward these goals―diet,
exercise, stress management, and more
Campaign Resources
 Developed a Provider
Toolkit that offers tools,
tips, and resources to help
organizations jump-start a
hypertension quality
improvement initiative
 The toolkit is organized
around each of the eight
campaign planks
 Regularly updated with
best practices shared by
groups
Campaign Resources
 MeasureUpPressureDown.com
 Facebook, Twitter, Flickr
 For Healthcare Professionals:
⁻ Provider Toolkit
⁻ Monthly webinars
 For Patients:
⁻ Circulation Nation: Your
Roadmap to Managing High
Blood Pressure
⁻ 10 patient tip sheets
Campaign Webinars
Date
Topic
Speaker(s)
January 16, 2014
Competency and Automated BP Cuffs
Beth Averbeck – HealthPartners
February 20, 2014
Medication Adherence
Elizabeth Oyekan – Kaiser National Pharmacy
March 20, 2014
Improved Blood Pressure Control Associated With a
Large-Scale Hypertension Program
Joseph Young – Kaiser Northern California
April 17, 2014
California’s Right Care Initiative
Parag Agnihotri – Sharp Rees-Stealy Medical Group
Scott Flinn – Arch Health Partners
May 15, 2014
Patient Engagement
Bill Polonsky – Behavioral Diabetes Institute
June 19, 2014
Medical Home and Hypertension and the Roles of
Care and Disease Manager
Fred Bloom – Geisinger Health System
July 17, 2014
EHRs and Improving Blood Pressure
Peter Basch – MedStar Physician Partners
August 21, 2014
Guidelines Updates
Larry Fine – NHLBI
September 18, 2014
Community Pharmacist Role
Rebecca Cupp – Ralphs Pharmacies
October 16, 2014
TBD
TBD
November 20, 2014
Implementing All Eight Planks
Michael Ogden – Cornerstone Health Care
December 18, 2014
Home BP Monitoring
Gbenga Ogedegbe – NYU School of Medicine
2013 Annual Report
National Day of Action:
Roll Up Your Sleeves!
Campaign Impact
Moving the Needle
Through data reporting and
analysis, the campaign will
determine:

Can we move the needle on
hypertension control? How
much?

What care processes lead to
better outcomes?
121
Early Results

In preliminary results from
Q1 2013 to Q2 2013, initial
data from 22 medical
groups showed:
⁻
Absolute increase of 2.8%
in blood pressure control
⁻ 4% relative improvement
in overall control rate
⁻ 30,000 more patients
with high blood pressure
are now in control, thanks
to Measure Up/Pressure
Down®
MUPD Hypertension Control Data
Success Stories
Coaches Deliver Motivation
In a major practice redesign, the Des Moines, Iowa, physician
group embedded nurse health coaches into the system to work
with more than 13,000 diabetic patients. Guided by patient
data and chart reviews, coaches reached out to those with poor
hypertension control and helped them manage their conditions
with food diaries and one-on-one motivational coaching. From
these efforts, the number of patients with blood pressure at
goal rose from 61 to 73 percent.
Success Stories
Transparency Holds Staff Accountable
In New Jersey, Summit Medical Group conducted a full year of
analysis and reported blinded control data to providers for
baseline metrics. They created and posted color-coded patient
lists to the intranet to help staff prioritize outreach to patients
for follow-up visits in a timely fashion. On a monthly basis, they
now distribute unblinded data across the organization via email, as well as updated patient lists. In just one quarter, rates
improved from 64 to 75 percent.
Success Stories
Accuracy Brings Improvement
At New West Physicians, all direct care staff were trained in
accurate blood pressure measurement through a lunch and
learn at each site and a self-teaching video for new hires.
Medical assistants are now empowered to flag hypertensive
patients by placing a blood pressure sticky note next to the
exam room keyboard to draw attention for physicians. The
Denver-based practice implemented four additional campaign
planks to improve patient control rates from 73 percent in 2012
to 79 percent in September 2013.
National Recognition
Kendra Gaskins
Director, Measure Up/Pressure
Down® & Chronic Care Initiatives
703-838-0033, ext. 346
[email protected]
Jennifer Cooper, MSN, RN, APHN-BC
Public Health Nursing Clinical Instructor,
Georgetown University School of
Nursing and Health Studies
128
Demonstrating Public
Health Nursing’s Support
of Million Hearts
ASTHO Support
The Association of State and Territorial Health
Officials (ASTHO) requested assistance from APHN
to support the Million Hearts™ Initiative by
providing ten state virtual learning collaborative
teams with public health nursing expert advice
and resources.
Ten ASTHO-supported teams:
Alabama, District of Columbia, Illinois, Maryland,
Minnesota, New Hampshire, New York, Ohio,
Oklahoma, and Vermont
APHN Role in the Project
1. Collect and categorize case studies of public health nurses
(PHNs) impacting cardiovascular disease, especially related
to hypertension prevention and control in communities
throughout the nation.
2. Coordinate with other national interested organizations
such as the American Heart Association, NACCHO, and the
National Association of Chronic Disease Directors.
3. Consult on the role and contribution of the PHN to the ten
state teams through PHN Peer Group monthly calls, in
person ASTHO supported partner meetings, and ongoing
communications.
4. Develop an Issue Brief about current and future PHNs roles
in the prevention and control of hypertension.
Why Should PHNs Be Involved in
Million Hearts?
Million Hearts™ provides an opportunity to work
with a national program
• Enumeration and Characterization of the Public Health
Nurse Workforce (2012)
• “…national initiatives provide new opportunities for
emerging roles in PHN focused on community health
promotion and prevention practices.” (Kulbok, Thatcher,
Park & Meszaros, 2012).
• Recommendations from the 2012 Future of Public Health
Nursing Forum & 2013 Quad Council Convening
Why Should PHNs Be Involved in
Million Hearts™?
It’s time to reach those at .risk for hypertension or
with hypertension at the POPULATION level
• The Million Hearts™ Initiative provides the framework and
evidence-base, but there is more work to do.
• We have learned that chronic conditions cannot be most
effectively treated only at the individual level.
• PHN has the tools to do this work at the population level.
For more information:
The Million Hearts™ Initiative: http://www.phnurse.org/
CDC playbook: https://practicalplaybook.org/
Themes from the Literature Review
Prevention
• Not center-stage yet, but on the stage.
Public Health
• What it has been and what it has become
Collaboration
• Primary Care + Public Health
Current and future reimbursement models
• Medicaid Waiver
• ACOs to ACCs
PHN Involvement
Partnerships
• New & Stronger Partnerships
Models of Care
• New Public Health Role & Relationships
PHN Roles
• Care Coordination
• Education to clients and care providers
• Screening/Referral
PHN Impact
Public Health Nurses are:
• Excited/Enthusiastic
• Developing New Tools
• Creating New Roles
• Thinking About the Future
ASTHO Issue Brief
• Topic areas
• An opportunity
• Plan to submit to ASTHO by June 30, 2014
• Publication will be posted on the APHN website
and QUAD Council websites, as approved.
“I skate to where the puck is going to be, not
where it has been”
-Wayne Gretzky
APHN Million Hearts™ Webinar
June 26, 2014
2:00-3:00 EDT
Charley John, PharmD Pharmacy
Supervisor Washington, DC, District318 Walgreens Company
Helping Patients Get, Stay, and Live Well
Charley John, PharmD
©2013 Walgreen Co. All rights reserved. Confidential and proprietary information.
Walgreens clinicians are the key to effective care
Our clinicians play a pivotal role:
• Trained Pharmacists and Nurse Practitioners
conduct Walgreens health testing
• Pharmacists and Nurse Practitioners generate
a high level of trust
• Walgreens clinicians leverage existing, faceto-face relationships with patients
• They provide testing through a highly
accessible network
• They follow up testing with calls to patients
and coordinate with primary care physicians
141
©2013 Walgreen Co. All rights reserved. Confidential and proprietary information.
Sample Follow Up and Referral Process
Health Testing Wellness Call
• Pharmacists make a follow-up wellness phone call for patients
who had results outside of the ideal range 3 to 5 days after
health test.
• The purpose of the phone call is to assess if the patient has
conducted a follow-up with their healthcare provider about their
tests results and address any additional questions that they
may have.
• The patient has the option of declining from a follow-up call
from the pharmacist.
• The pharmacist must also document a completed or declined
follow up call.
Clinician Interventions Deliver Better Outcomes
Testing uncovers unmet medical needs. Testing in retail
locations effectively encourages appropriate care.
33%
40%
40% have results that are
outside of normal ranges.
About one-third of those make
follow-up appointments
Source: Walgreens Health Outcomes
©2013 Walgreen Co. All rights reserved. Confidential and proprietary information.
144
Sneak Preview: Effects on Adherence
 501,495 patients received 1 or more blood pressure tests
at Walgreens stores in 2012.
 123,427 were existing patients, age ≥18, and reported
having hypertension, of which:
1. 58.47% had a blood pressure test result outside the normal
range.
2. 41.08% had no anti-hypertensive Rx history prior to their blood
pressure tests.
 Patients with an abnormal blood pressure result are more
likely to be non-adherent or not on any anti-hypertensive
medications prior to the test
Thank you!
Gina Pistulka, PhD, MPH, RN Chief
Nurse Officer, Capital Clinical
Integrated Network
Capital Clinical Integrated Network
CCIN
Gina Pistulka, CNO
DC Million Hearts Meeting
May 21, 2014
History
• Funded by the Center for Medicare and Medicaid
Services Innovation to Create an Integrated Care
Coordination and Care Delivery System
• Collaborative grant application process by Mary’s
Center, Providence Hospital, Unity, DCPCA, La
Clinica del Pueblo, So Others Might Eat, DC
Chartered Health and United Healthcare
• 14.9 Million over 3 years
• Grant Period: July 1, 2012 – June 30, 2015
• Grantee: Mary’s Center
149
Problem
• District residents are not feeling engaged in their
own healthcare or are not engaging with their
PCP to manage illness and receive preventative
health services.
• Residents do not understand the way to utilize
the healthcare system based on level of acuity of
illness or need.
• Residents are dealing with a multitude of
concerns in terms of housing, abuse, violence,
mental health concerns and poverty; health is
often not factored into their every day.
150
One Solution: CCIN
• CCIN is positioned to assist individuals and
families in understanding the appropriate use of
the healthcare system, address barriers that
prevent engagement and coach to support
behaviors related to improved health.
• CCIN is working with a diverse set of
stakeholders/service providers in the District
(Hospitals, Community Health Clinics, MCOs,
DHCF) to address system-wide barriers and
improve efficiencies with access, quality,
coordination and communication.
151
Overarching Aim
• To improve health and reduce overall
healthcare costs for a high-cost, hard-toreach District of Columbia Medicaid
population that has been diagnosed with
chronic illness and has complex healthcare
needs.
152
Goals & Objectives
• Improve access and coordination of care
within the healthcare system within the
District of Columbia. (key linkages,
partnerships, technology)
• Improve the health of the CCIN
participant population (HEDIS Measures)
• Reduce healthcare costs incurred by CCIN
participants over 3 years
153
Our Partners and Subscribers
CURRENT PARTNERS
•
•
•
•
•
•
•
•
•
•
•
•
•
Bread for the City
La Clinica del Pueblo
Mary’s Center
So Others Might Eat
Providence Hospital
Children’s National Medical Center
Unity Health Care
AmeriHealth DC
Trusted
DC Primary Care Association
DC Healthcare Finance
Medical Mall
Core Service Agencies (Green Door, Life Stride, Mary’s Center)
154
Capital Clinic Integrated Network (CCIN)
VISION
Mary’s Center
Consumer Engagement
PHR
La Clinica del Pueblo
So Other’s Might Eat
Bread for the City
Transportation
Services
Providence Hospital &
Physician Enterprises
Other
Hospitals/Clinics
UNITY
Healthcare
Vitals Sign
monitoring
Communications
& Collaboration
eVisit
Care Management
Health
Community
Secure Messaging
Analytical
Services
(PCMH,
ACO,HEDIS,
Million Hearts)
CCIN’s Interoperability Services - Syntranet
(HEDIS, GPRO, ACO, PQRS, UDS, MU)
Connectivity, Security and Management (HIPAA HITECH)
Quarterly Claims
Utilization
Analysis
Governance/
HIE Mgmt
Services
Hospital ENS
Labs, Rad, TCM
Population
Stratification/
Registries
CCIN CARE COORDINATION
SERVICES
156
Population Health
Management
Claims data,
referral from
Transitional Care
Services, other
ID target
Population Risk
Assessment
Improve
outcomes
Behavior
Modification
CCIN
Consent
Connect to
Medical
Home
High touch
Intervention
157
Patient Selection
• Selection based on Total Cost of Care (Source:
Medicaid data)
• Risk related to a diverse pool of health conditions
• All Wards in the District of Columbia
• Targeting the Key Cost Drivers:
– Targeted pharmaceutical costs
– Emergency room visits
– Admissions to hospitals
– Re-admission to hospital
– Emergency medical transportation costs
– Specialists costs
158
Staff
• RN Care Coordinators (RNCCs)
–
–
–
–
–
Supervise CHWs
Guide Care Plans
Respond to health/clinical issues
Medication reconciliation
Health education
• Community Health Workers (CHWs)
– Meet the participant where they are
– Address barriers
– Coach, educate, motivate, navigate participants
CCIN - Capital Clinical Intergrated Network
159
Our Model at Work
• Follow up with referrals from PCPs, Medical Mall, Hospitals and
MCOs on participants who are at high risk due to health
condition or usage of the healthcare system
• Peer-to-peer outreach, education and consent to participants
• Meet with participant in home/community location, conduct
Health Risk Assessment and develop patient-centered care plan
• Facilitate a relationship with the PCP and the clinic-based care
team
• Provide resources to CCIN participants to prevent visits to ED, to
take medications on time, visit their PCP or specialist, improve
the control of their illness, or need support for referral to mental
health provider
• Provide transportation options
160
Health Behavior Change
• Primary Care and Health Homes
– Understanding of the role of primary care
• Emergency Room vs. Urgent Care vs.
Walk-in Clinic
• Prescription Adherence
• Lifestyle Issues
• Finding Transportation Options
161
CCIN Activities with
Participants with Hypertension
• Support participant to understand HTN as a
chronic illness and complications related to HTN
• Support participant in self-monitoring HTN
(documenting BP, danger symptoms)
• Coach participant to…
–
–
–
–
–
–
Attend appointments with the PCP
Take medication as prescribed
Discuss symptoms with PCP
Make healthy food choices
Increase activity
Use stress reducing techniques
CCIN - Capital Clinical Intergrated Network
162
Stories from the Field
• Participants are not taking medication as prescribed
(problems with pharmacy, literacy, English language,
misunderstand PCP, polypharmacy, side effects)
• Perception that control = cure
• CHWs and RNCCs have helped participants to
understand HTN goals and why they should control
blood pressure.
• Participants are documenting and showing PCPs their
readings.
• Making changes in what they are eating and pattern of
eating
• Taking small steps (some large) to overcome a mental
block of exercise and increasing activity levels
CCIN - Capital Clinical Intergrated Network
163
Reflections
• CHWs work all over the city and are gaining trust
by participants by showing up where others will
not go.
• CHWs are well-received and build a trusting
relationship that allows the participant to be open.
• Participants relate to CHWs as peers - CHWs
bridge the gap between the HC system and the
community.
• CHWs have the time to understand the difficulties
experienced by a participant and have the tools to
educate and coach the participant to take action
that promotes health and lifestyle changes.
CCIN - Capital Clinical Intergrated Network
164
Thank you!
• Contact Information:
Gina Pistulka
CCIN Chief Nursing Officer
1400 L. St. NW, Suite 300
Washington, DC 20005
[email protected]
Cell: 410-404-3905
165
Freya Spielberg, MD, MPH Associate
Professor Department of Prevention and
Community Health, Director of Community
Oriented Primary Care, George Washington
University
CCIN - Capital Clinical Intergrated Network
166
A New Approach to
Community Health
Quality Improvement
Freya Spielberg MD MPH
Director Community Oriented Primary Care
Director Research and Evaluation Rodham Institute
A New Recipe for Community Health Quality
Improvement (CHQI)
 Diverse Partnerships – Student Engagement
 Community Oriented Primary Care
 The Quadruple Aim
 The Prevention to Care Continuum
 Workflow Redesign with Prioritization
 Ideas for Test of Change
 Return on Investment
Community Oriented Primary Care– An
Innovation Model
Community Oriented Primary Care
Community
Diagnosis
Prioritization
Evaluation
Quadruple Aim
Assessment
Implementation
Intervention
Planning
The Quadruple Aim
 Better Health Outcomes
 Better Patient Experience
 Lower Cost
 Decreased Health Disparities
Hypertension in Washington, DC
(Trust for America's Health, 2011)
The Hypertension Prevention + Care Cascade
(20 DC clinics, Hypertension in 2013)
100%
90%
80%
70%
60%
80%
50%
Ideal
65%
Goal
40%
Current
36%
30%
20%
10%
0%
Diagnosis
Retained in Care
Controlled BP
Community Health Quality Improvement Process
 Patient interviews
 Stake Holder Interviews - Work flow analysis
Identify evidence based interventions and complete
prioritization process
 Work flow analysis and redesign
 Design test of change
 Return on Investment Analysis
Patient Interviews - What Hypertensive Patients
Are Saying at the Health Center...
“Too many fast food places surrounding me. Maybe there should be a farmers
market outside the clinic.”
“The Clinic could give more handouts about salt.”
“Smoking cessation, exercise, and nutrition classes at the clinic would help
me [control my blood pressure].”
“Learning from peers [about controlling blood pressure] at the clinic would
help me.”
Current Workflow with Barriers & Solutions
Prioritization
Likely to
substanti
ally
improve
health
outcomes
Likely
to
lower
health
care
costs
Likely to
improve
patient
experie
nce
Likely
to
decrea
se
health
dispari
ty
Likely to
be
feasible
to
impleme
nt in one
year
Likely to
be
affordab
le to
impleme
nt
Total
Score
Nutbeam, D. (2000). Health
literacy as a public health goal:
a challenge for contemporary
health education and
communication strategies into
the 21st century. Health
Promotion International, 15(3),
259-267.
3
3
3
2
3
1
15
Free, C., Phillips, G., Galli, L.,
et al. (2013). The effectiveness
of mobile-health technologybased health behaviour change
or disease management
interventions for health care
consumers: a systematic
review. PLoS medicine, 10(1),
e1001362.
3
3
3
2
3
2
16
Barriers
Solutio
ns
Evidence
- Poor health
literacy
- Lack of resource
referrals
Wellnes
s/
Health
Educati
on
Progra
ms
- Lack of resource
referrals
- Poor health
literacy
- Lack of tracking
of Rx refilling
- Lack of system
to track BP,
meds, symptoms
at home
- Unable to reach
patients for
Mobile
Health
Tool
Mann DM. Kudesia V. Reddy S.
Weng M. Imler D. Quintiliani L.
(2013). “Development of DASH
mobile: a mHealth lifestyle
change intervention for the
management of hypertension.”
Studies in Health Technology
Prioritization
Barriers
Solution
s
Evidence
Likely
to
substan
tially
improve
health
outcom
es
Likely
to
lower
healthc
are
costs
Likely to
improve
patient
experie
nce
Likely
to
decrea
se
health
dispari
ty
Likely to
be
feasible
to
impleme
nt in one
year
Likely to
be
affordab
le to
impleme
nt
Tota
l
Sco
re
- Access to
heart healthy
foods
Home
Food
Delivery
Program
Troyer, J. L., Racine, E. F.,
Ngugi, G. W., & McAuley, W. J.
(2010). The effect of homedelivered Dietary Approach to
Stop Hypertension (DASH)
meals on the diets of older
adults with cardiovascular
disease. The American journal
of clinical nutrition, 91(5), 12041212.
3
2
1
2
1
1
10
- Access to
heart healthy
foods
- Culture
shapes daily
diet
Access to
Healthy,
Cultural
Food
Substitute
s&
Education
Ard, J. D., Rosati, R., &
Oddone, E. Z. (2000).
Culturally-sensitive weight loss
program produces significant
reduction in weight, blood
pressure, and cholesterol in
eight weeks. Journal of the
National Medical Association,
92(11), 515.
2
2
1
2
3
3
14
Anderson-Loftin, W., Barnett,
S., Bunn, P., Sullivan, P.,
Hussey, J., & Tavakoli, A.
(2005). Soul Food Light
Culturally Competent Diabetes
Basic Features of mHealth Tools
Source: Be Well Mobile
Redesigned Workflow
BP Control From the Community to the Clinic
Community
CHW Reconnect to Care (high BP, missed visit,
ER visits>1, Hospital discharge)
CHW
POC
Test
Home
Early
Dx
Early
Tx
Cx
to Care
Txt Message, Care Plan Management - Need
Testing, Counseling, Medical Care, Behavioral
Care, Social support, Linkage support
Impact
BP
Stroke
CAD
Dialysis
Cost
ER
Hospital
Pt Exp
Easy
Conven.
Cult. Ap.
Community to Clinic – IT Integration
CHW
BP Testing
Counseling
and Linkage
Care Plan
Primary
Care
Specialty
Care
Missed Visits
BP
Care Plan
Missed Visits
BP
Procedures
Care Plan
Hospital
Care
Insurance
MCO
ER visits
Hospital visits
BP
Care Plan
$ Meds filled
$ Patient Lists
Visit Costs
Care Plan
Benefits of IT Integration – One integrated care plan instead of five
CHW: Can get lists to target high $ clients and high BP clients for additional care management
Primary Care
•
Can get counseling and testing data from CHW to improve linkage and risk reduction.
•
Can get daily hospital and lab data to identify patients in need of additional care management.
•
Can get billing data to determine ROI for health improvement efforts
•
Can access off-site lab and procedure data to reduce duplicative ordering
•
Can access off-site integrated care plan to improve coordination of care
Specialty Care: Can access and add to integrated care plan to improve quality of care
Hospital:
•
Can decrease readmissions by supporting integrated care plan
•
Can improve quality and efficiency of care with access to primary and specialty data
Insurance: Can decrease costs by supporting implementation of integrated care plan
ROI Estimation: Assumptions
Assumptions: ROI of Barbershop Intervention for All Hypertensive
African American Men in Ward 5
P
57,217
2010 Estimate – Ward 5 African Americans (Neighborhood Info. DC)10
MI/ST
Rates
MI 4.9%,
ST 5.5%
2011 DC-wide averages for African Americans. Assumes MI and Stroke rates are
equal for women and men. (DC BRFFS)11
MI/ST
1,402 MI,
1,574 ST
Estimated number of MI & ST among Ward 5 AA men. Assumes 50% of Ward 5
African Americans are male.
SI/DI
15% lower
risk for MI
& ST
Assumes intervention will achieve a mean drop in SBP of 7.8% and mean drop of
2.8% for DBP. (Victor, et al BARER-1 Trial)12
PMI/P
ST
210 MI,
236, ST
Estimated number of MI & ST prevented among Ward 5 AA men. Assumes 15%
reduction in risk for both MI & ST. (Al-Ansary, et al)13
CM/C
S
$20,264
MI,
$13,884
ST
Cost is mean cost per hospital stay per MI or ST. Original price was in 2004 dollars
and was converted to 2014 dollars using an online tool and the average Consumer
Price Index for that year. (HCUP)14
CI
$427,700
Assumes $50/person - cost designed for intervention to be cost-neutral in 1st year.
Original estimate assumed that every black-owned barbershop in America would
implement the program (18,000 shops); $5,800/shop. Assumes 8,554 participants
– All AA men in Ward 5 with hypertension (uses DC-wide HTN estimate 29.9%
prevalence, probably very conservative). The cost will probably be lower in
ROI Estimation
 ROI= (Savings from intervention – Cost of intervention)/Cost of
Intervention
 ROI = (PMIxCM + PSTxCS) – CI / CI
 = [(210x$20,264 + 236x$13,885) – $50x8,554 ]/ $50x8,554
 = [($4,331,040 + $3,276,860) – $427,700 ]/ $427,700
 = 16.8 ROI
Questions?
• [email protected]
Thank You for Participating
For Additional Information:
Delmarva Foundation of the District of Columbia
http://dcqio.org
The District of Columbia Department of Health
http://doh.dc.gov/
Please complete and return your
Meeting Evaluation
to any of the staff members before
leaving the session.
Thank You.
This material was prepared by Delmarva Foundation of the District of Columbia (DFDC), the Medicare Quality Improvement Organization for the District of
Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The
contents presented do not necessarily reflect CMS policy. 10SOW-DC-IHPC-052214-634