12 20 2017 Whats New in Hypertension

12 20 2017 Whats New in Hypertension


– Hello everyone, welcome
thank you for joining our December LAN event
talking about hypertension. I’m Rebecca at HealthInsight,
I’m a project manager here. A panel of great presenters
here with use today. We’re just gonna dive right
in, it’s the top of the hour. People may join at we go
along, but that’s okay. We’re gonna get started anyway. We’re gonna talk about what’s new in the discussion about hypertension. We’ve got Dr. Barry Stults from the University of Utah Medical Center. He’s gonna be talking
about the new guidelines that were just released last month. And then we’ve got Carrie
and Jaime from clinics here in Salt Lake City, Utah, who have implemented some successful home blood pressure monitoring programs and we really want you to
hear what they’ve done and take some away from that. A little bit about the
Zoom platform before we get started here, to get you familiar. If you hover your mouse along
the bottom of your screen you should see a black tool bar similar to the one that’s on the screen. On the far left are the
mute and camera functions. So some of you have cameras turned on. If you don’t want them to be turned on you can click that start video button and it will turn your camera off for you. But right now some of
you have your cameras on, so heads about that. And the mute function is there as well. To the left of center
is a participant tab, you can click that to see who else is on the call with us today. You can raise your hand from there, you can also mute and
control your video camera from that as well. To the right of center is chat. And in the chat a box will appear. And you have the ability on the bottom to send it to everyone or to the host, when we really encourage to change that function to everyone. As a matter of fact I’d you
all to do that right now, click on chat, click
change it to everyone, and type in your setting. Are you a physician office,
are you home health, are you hospital? Give us a little bit of an
idea of where you are from. And a little bit about HealthInsight. We’re facilitating this call today we’re the Quality Innovation Network, Quality improvement Organization. We align with the CMS Quality Strategy and help with quality improvement work in the four states, Oregon,
Nevada, Utah and New Mexico. So like I said, we’re
gonna cruise right through ’cause we have so many
great presentations today, I don’t want to waste any time. The ACC/AHA 2017 Hypertention Guidelines are gonna be talked about
my Dr. Barry Stults, from the University of
Utah Medical Center. You will all be receiving these slides after the presentation so you can read everyone’s full bios. But he is a general internist
and has some special interest in the management of
resistant hypertension, so we are thrilled to have
him here with us, today. With that I turn it
over to you Dr. Stults. – Thank you. Let’s look at some of the selective and clinically relevant recommendations that have come from this guideline, which was just released
one month ago here. This guideline first was commissioned by the National Heart, Lung
and Blood Institute in 2014. And it has been reviewed and accepted by 11 other medical societies,
which you see listed here. Of note about three days ago, the American Academy of Family Practice has decided not to
accept these guidelines, or the blood pressure
levels that are suggested which we’ll discuss. The scope of this document is impressive, it’s very comprehensive. It covers diagnosis, treatment, prevention and the plan of care for
patients with hypertension. It incorporates 47 subsections
in 169 online pages and it includes 106 evidence
based graded recommendations that are based not only on
randomized clinical trials and meta-analysis of those trials, but also on observational
studies and on expert opinion. The document is available free at the American College of Cardiology website that you see listed on this slide. Well this slide shows you
that the ranking system, both for the class and
strength of the recommendation and the level of evidence. And most of the slides I
have tried to incorporate what the class or strength
of recommendation is, and what the level of
supporting information and research is. So, to summarize, what’s new in the ACC/AHA 2017 Hypertension Guideline? It includes a new blood
pressure classification scheme, new target blood pressure levels, new hypertension drug
therapy recommendations that are according not only to the level of blood pressure in the patient, but also that patient’s 10 year level of cardiovascular risk,
specifically their risk of a fatal or non-fatal
myocardial infarction and stroke. It includes a recommendation
for initial low dose two drug therapy, rather
than single drug therapy for most patients with hypertension. And finally it has a recommendation to adjust drug therapy using
both office blood pressure and home blood pressure. Let’s look at each of these
concepts in more detail along with some of the supporting evidence for these recommendations. Well this is the new
ACC/AHA 2017 Classification of blood pressure, as compared to the JNC-7, 2003 guideline. Note that the ACC 2017 guideline, also defines normal blood pressure as a pressure below 120 over
80 milometers of mercury. However, a blood pressure of
120 to 129 over less than 80, is now defined as elevated blood pressure. And hypertension is now
defined as a blood pressure 130 over 80 or higher, rather than 140 over 90 or higher. And stage one hypertension is now defined as a blood pressure of
130 to 139 over 80 to 89 with stage two hypertension
as a blood pressure 140 over 90 or higher. Well, why do we have a new
classification of blood pressure? Several reasons. First we’ve known for many years from observational studies, that there is a log-linear
progressive increase in cardiovascular risk,
as systolic blood pressure increases above 115 milometers of mercury. Each two milometer increase
in systolic pressure above 115, increases the
risk of stroke death by 10% and myocardial infarction death by 7%. As a result, an elevated
systolic blood pressure, ACC/AHA definition of 120 to 129, increases the risk of
a cardiovascular event, between 10 to 50%. But more important, stage one hypertension with a blood pressure of 130 to 139, increases that cardiovascular
risk by 50 to 100%, compared to a normal blood pressure less than 120 over 80. 25% of the US adult population has a systolic blood pressure
between (audio stop). Now (audio faded), blood pressures are less than 140 over 90. And finally as we’ll
see, recent meta-analysis indicate the benefit of
lower, of drug therapy for lower blood pressure levels. As an example, this is a meta-analysis of 123 randomized trials that had more than 600,000 patients. And it showed similar relative reduction, relative risk reductions in
major cardiovascular events, of between 20 and 37%, independently of whether the initial baseline blood pressure was above 160, or it was 150 to 159, 140 to 149, even 100 to 139, or even below 130. These relative risk
reductions were present in patients both with and
without coronary heart disease, stroke, heart failure, diabetes,
or chronic kidney disease. Another meta-analysis
of 34 randomized trials with 138,000 patients, found similar relative risk reductions in major cardiovascular
events of 24 to 31%. Looking at final achieved blood pressures whether those achieved blood
pressures were 140 to 149, or compared to above 150, 130
to 139 compared to above 140. Or less than 130 compared to above 130. Cardiovascular events
continue to be reduced down to a systolic blood pressure of 122 milometers of mercury. And there are substantial,
absolute risk reductions in cardiovascular events. It does appear that lower is better. Well, one of the some of the consequences of the new ACC/AHA Blood
Pressure Classification scheme? It increased the
prevalence of hypertension and it magnifies hypertension
as a public health epidemic. Compared to the JNC-7
definitions of hypertension, the ACC/AHA classification, increases the prevalence of hypertension from 31% to 46% of adult Americans. That is 72 million to 103
million American adults. And these new prevalence
levels are all differ according to race and age as
you see listed on the slide. However, as we’ll discuss
a little bit later, this guideline suggests
either new or intensified drug therapy, for only
12 million more persons in the United States, not a lot. Well, the new ACC/AHA
guideline appropriately focuses on the essential need for accurate office blood pressure measurement, to screen for hypertension, but not to diagnose hypertension. Of concern to me is no
specific recommendation is made in this guideline to use automated office
blood pressure measurement performed on patients who
are completely isolated within the exam room. That is termed in the
medical literature now as quote, AOBP, end quote. But there are these two
supportive statements. Automated oscillometric
devices provide an opportunity to obtain repeated measurements
without a provider present. Thereby minimizing the potential
for a white-coat effect. And that’s really the
key thing that AOBP does. Second, there is a growing evidence base supporting the use of
automated office blood pressure measurements, preformed with
patients in complete isolation. Similar to other recent guidelines, the ACC/AHA guideline emphasizes that out of office blood
pressure measurement with either 24 hour ambulatory
blood pressure monitoring, consider the gold standard. Or with home blood pressure monitoring if 24 hour monitoring is not available, is necessary and mandatory
to accurately diagnose hypertension and rule out
white-coat hypertension. But the new ACC/AHA guideline goes a step further than other guidelines. It also recommends that
we strongly consider out of office blood pressure measurement to both detect and treat
masked hypertension, where out of office blood
pressure is consistently higher than office blood pressure. Inpatients whose office
systolic blood pressure is 120 to 129 milometers of mercury, further increasing the need for accurate home blood pressure measurement. Well, this diagram
summarizes the algorithm from the ACC/AHA for out of office blood pressure measurement, both to detect white-coat hypertension
on the left of the slide. But also to detect masked hypertension, particularly in patients at
elevated cardiovascular risk, on the right side of the slide. And I’ll let you take a
look at that at your leisure to get more detail from it. This slide, which I’ll also
allow you to take a look at later in more detail, shows
the ACC/AHA recommended algorithm for considering out of office blood pressure measurement,
to detect white-coat effect and masked, uncontrolled
hypertension in treated patients. Previous slide was for untreated patients, this one is for treated patients. Again, detecting mass hypertension where the blood pressure
is higher out of the clinic than in the clinic, is
most useful in patients with clinical cardiovascular disease or patients who were at
high cardiovascular risk. Well, another key recommendation in the ACC/AHA 2017 guideline is to base pharmacologic
drug treatment decisions not only on a patient’s
blood pressure level, but also on their 10 year risk
of cardiovascular disease, fatal and non-fatal myocardial
infarction and stroke. Randomized trials, as
well as simulation studies have suggested that this
approach will prevent more cardiovascular events
and be more cost effective than basing decisions on
blood pressure level alone. The guideline recommends
use of the ACC/AHA Pooled Cohort Equations, which is available online at the website at the bottom of this slide. To calculate a patient’s
10 year cardiovascular risk if they are a primary prevention patient, under age 65 and they don’t
have cardiovascular disease, chronic kidney disease or diabetes. Note the 10 year
cardiovascular risk is already 10% or higher in 90% of
patients age 65 and over, regardless of their risk factors. And in literally 100% of
patients age 75 and over and in all patients with
clinical cardiovascular disease, chronic kidney disease or diabetes. You do not need to
calculate the 10 year risk in those patients, it’s already high. Well, this next slide shows the ACC/AHA blood pressure thresholds
for initiating drug treatment and the blood pressure goals, well I thought I did. Yes, this one does. This slide shows the
thresholds for initiating drug treatment and the
blood pressure goals for treated patients. As you see, patients with
cardiovascular disease or a calculated 10 year
cardiovascular risk of 10% of higher, or age 65 and over, if they are ambulatory
and community dwelling, or if they have diabetes
or chronic kidney disease. All of those patient groups
should receive drug therapy if blood pressure is 130 over 80 or higher and they should be treated
to a blood pressure lower than 130 over 80 milometers of mercury. In contrast, patients with
a 10 year cardiovascular risk less than 10%, or patients who have had a prior stroke, should be treated with drug therapy, if blood pressure is
140 over 90 or higher. And again, those patients
should be treated to a blood pressure less than 130 over 80. This slide summarizes the
ACC/AHA 2017 recommendation for both lifestyle and
pharmacologic therapy. Note that patients on
the left of the slide who have an elevated
blood pressure 120 to 129, less than 80, receive
lifestyle therapy alone. Patients with stage one hypertension with a blood pressure of
130 to 139 over 80 to 89, if they have a 10 year cardiovascular risk less than 10%, receive only lifestyle medication therapy, no pharmacologic therapy
for those patients. On the other hand, patients
with stage one hypertension, 130 to 139 over 80 to 89, whose 10 year cardiovascular
risk is 10% or higher and all stage two patients
with a blood pressure 140 over 90 or higher, receive both lifestyle
modification and drug therapy and are followed up every month, until their blood pressure is controlled to below 130 over 80. Supporting data for these
blood pressure thresholds and target blood pressure levels, for patients with a blood
pressure 140 over 90 or higher, but a 10 year cardiovascular
risk less than 10%, are derived from the
meta-analysis that are summarized and listed on this slide. Including the new ACC/AHA meta-analysis of randomized trials, that
indicates a 16% reduction in major cardiovascular events. By lowering systolic pressure below 130, as compared to leaving it 130 or higher in patients with a less than 10%, 10 year cardiovascular risk. Once white-coat hypertension
has been ruled out, the ACC/AHA guideline recommends on the left side of the slide, initial one drug therapy for patients with a systolic blood pressure, 130 to 139 and a 10 year cardiovascular
risk of 10% or higher. They suggest a diuretic
or calcium channel blocker for African Americans and any of the four major drug
classes for other patients. Note that beta blockers should be used only for patients with
ischemic heart disease or heart failure in
coexisting hypertension. In contrast, on the
right side of the slide, initial low dose two drug
therapy at the very beginning is recommended for patients
with a blood pressure 150 over 90 or higher. And initial low dose two drug therapy may also be considered for
patients whose baseline pressures are 140 to 149 provided
that standing blood pressure is not low, that the patient is not
very elderly or frail, and that there are not prior issues with either hypertension,
low blood pressure or multiple drug intolerances. And the last slide that
we’ll talk about here is why is the ACC/AHA now recommending initial, low dose two drug therapy, rather than initial one drug
therapy for most patients? Several reasons. First, more than 75% of
hypertension patients, need two drugs to lower
their blood pressure below 140 over 90, let
alone below 130 over 80. Second, the studies,
both randomized trials and observational studies,
show that initial, low dose two drug therapy,
is more effective, more efficient and more tolerable than maximum doses of a single drug. You get greater blood pressure
lowering at six weeks, with initial low dose, two drug therapy. You get better hypertension control over the first three to
12 months of treatment. You reduce cardiovascular
events in the first six months in patients at high cardiovascular risk, and in most patients
after one to two years. In addition, because side
effects are proportional to dose for most drugs, fewer side effects are
present, which will improve patient adherence to therapy. In addition, initial low
dose, two drug therapy results in fewer drug titrations, and thereby fewer office visits. And if you can use
single pill combinations for your patients, it reduces
their number of copays. – [Rebecca] Excellent. Thank you so much Dr. Stults. Now we have time for
about five to 10 minutes worth of questions if you’ve got them. So you can either type them into the chat, we’ll read them out. You also do have the
ability to unmute yourself and ask your question out loud, which you are more than welcome to do. So I’ll pause while you think of some questions. I’m curious how many people have you know really heard much
about the guidelines yet, or at least heard them summarized and what your reactions were. I’m sure there are some questions about this and see how they shake out. – Well while we’re waiting for a question let me point out that
about two or three days ago the American Academy of Family Practice, said that they are not
accepting these guidelines. They will continue to
follow JNC-8 guidelines, where in persons age 60 and over the blood pressure goal
is below 150 over 90, not even below 140 over 90, simply below 150 over 90. They have not published a detailed list of reasons why they
don’t like these guidelines, but in their statement they
suggest that they don’t believe these guidelines are fully evidence based. So there will be controversy. – [Rebecca] All right a little
time for the dust to settle. And maybe while we’re waiting too, for any questions to come
in, our next presentations are going to be about Home
blood pressure monitoring and setting up those kinds of programs. You know there’s some guidance
in these new guidelines about the use of that
and if there’s any more you want to say in support of that–
– The new guidelines defined an incredibly strong role for home blood pressure monitoring, both in the initial
diagnosis of hypertension, which requires out of office
blood pressure measurement. And note that I said requires. But also for managing
therapy both up and down. This is the way to go. – [Rebecca] Great. – [Edie] There are
currently no chat questions. – [Rebecca] Okay. Anybody want to unmute
themselves and ask a question? I’ll pause again for a few more seconds. – [Edie] We do have one question, do the guidelines document life changes? – Yes, the guidelines
see a very important role for lifestyle modification. Note that for patients with
elevated blood pressure 120 to 129 over less than 80, vigorous lifestyle recommendations should be provided to every patient. For patients with blood
pressure of 130 to 139 over 80 to 89, who have a less than 10 year risk of, less than 10% 10 year risk
of heart attack and stroke, those patients do not
receive drug therapy. Those patients receive vigorous
lifestyle modification, which is detailed in many
pages in these guidelines. Lifestyle therapy, very
important for all patients. But especially it’s the only
therapy for those patients in the two categories I just listed. – [Rebecca] Good question. So do you anticipate, I
mean obviously this is going to have some impact at some point, I would imagine on the
quality measure reporting that everyone has to do. – Well that isn’t one concern that the American Academy of Family
Practice appropriately brought up, is what is gonna happen with the requirements? That we don’t have a grasp. I think the essence of
the ACC/AHA guidelines is that lower levels of blood pressure are killing Americans
and we aren’t taking care of those levels of blood pressure. – [Rebecca] So yes, and
in the new guidelines, kind of the younger population there’s probably
gonna be a little more focus on that and like the question
before lifestyle changes and some of that. – Yeah we know that in patients
there are seven million Americans between the ages of 18 and 39, who have a blood pressure
140 over 90 or higher, let alone 130 over 80 or higher. And only about 1/3 of those patients have their blood pressure controlled. Below 140 over 90, let alone 130 over 80. – [Rebecca] Any final
questions before we move to the presentations about home
blood pressure monitoring? – [Edie] And there are none in chat. – Okay. – My name is Catherine
Luke and it’s my pleasure to introduce, I don’t know
if I can get in camera here. Hello. My pleasure to introduce our two speakers who will be talking about home
blood pressure monitoring. Thank you Dr. Stults for
that excellent presentation. One solution to getting those required measurements is home blood
pressure monitoring programs. Our first presenter is Carrie Jernigan, Quality Manager at Ogden Clinic. Carrie is an RN with over
15 years of experience and currently oversees quality standards, best practices and organizational goals across Ogden Clinics. Our second presenter, Jaime Fitzgerald is the Nurse Care Coordinator
for Exodus Clinics. Jaime is an RN as well,
she moved to the US from Australia in 1999 and is passionate about patient outcomes. Both our presenters are
leaders in their fields and we’re pleased to have them here to talk about their home blood
pressure monitoring programs. Carrie. – Well thank you I
appreciate the invitation from HealthInsight to present today. They were instrumental in the success of our project as we’re (audio warbles) Morgan Health Department at Utah Department of Health and so we want to recognize
them for their efforts in the success of this project. A little bit about Ogden Clinic. We are a multi-specialty practice with over 130 providers. Our footprint spans two counties. 22 specialties, 16
locations and eight of those were participating
family medicine locations in this project. So the why, when, who and how. The obvious why is that
blood pressure control correlates in prevention of
stroke and cardiac events. And that was really our main focus is, is wanting to impact the
health of our patients. And we also recognize
that multiple quality and payer programs include that blood pressure control measure. And so we wanted to affect our
performance levels as well. We recognized however that we lacked a consistent protocol across the multiple locations as well as tools. And that there was a need for
consistent staff education. So this all began back
in January, 2016 when we received some grant
money to explore this controlling of blood pressure
through having the patients monitor their home blood pressures. And we rolled it out
at two pilot locations of our family medicine, at
our family medicine clinics. And then there was a secondary,
phase two of this project that happened in July of 2016. And it extended to the six remaining family medicine locations in our group. The target patient that we wanted aim at improving blood pressure
were often newly diagnosed hypertensive patients, as
well as previously diagnosed hypertensive patients, who
were remaining uncontrolled. And our process to make those
changes were to incorporate patient education and blood pressure logs, as well as blood pressure monitors to be used as loaners for self monitoring, to determine if the patient
was truly hypertensive versus a white-coat hypertension syndrome. So these are some of our resources. Our patient education booklet, it incorporated various
different components to anywhere from prevention
to what’s considered high blood pressure. It identified when to call your provider and also had a list of
medications on the back, so that they could use that
as a resource as they traveled from clinic to clinic
and amongst providers. As well, some blood pressure
monitors that we used in each of the locations
and used as loaners, so that the patient can take
those home and determine if they truly, when they
came back if they truly had an issue with some hypertension. We recognized that our
biggest resource was our staff and that there was a
need for us to improve, to educate them on correct technique. And we used the measure up
pressure down video to do that, as well as promoting the project. We needed to educate not only
on the correct technique, but also on what the expectations
were for the project. And we also felt it was important to have some staff accountability. So we assigned a project
lead at each location. And they twice a month would
join us on conference calls where we could discuss
the successes and barriers that people were noticing
amongst all locations. And be able to make adjustments on the fly based on those barriers. We also ran reports early on to identify the expected enrollment at each location based on previous hypertensive measurements, and then we also provided staff incentives through monthly drawings for
those who were enrolling. And we had a project status poster at each of the sites that indicated, that identified expected enrollment and their progress towards that number. So the change process
that we identified was to identify the patient, educate the patient, evaluate the progress
and hopefully the patient at that point would
graduate from our program. So we identify the patient
at the point of care. These were again, either
newly diagnosed patients or previously diagnosed patients
who were poorly controlled. And at that point they
would transfer to the RN and the patient would be educated on blood pressure management and given the booklet with instructions on how to
use the blood pressure monitor at home that was given as a loaner. We also gave, in the education
there were recommended blood pressure cuffs based
on best practices and best recommendations in the industry. And so, we provided that information to them. And then they were
instructed to monitor their blood pressure for one
week with the loaner cuff and return to the clinic for evaluation. At that time when they
returned then they would visit with the RN and
the RN would look over the log with them and
determine if the provider needed to be notified
and whether any other interventions needed
to occur at that time. Depending on that, on
the course of that visit then they would also
follow up at one month with the patient’s provider, and again at three
months with either the RN or the provider to
determine whether or not they could graduate from the program, because they had some
stabilized blood pressure. Our phase one locations, these
are the final results here. Our enrollment for the two
pilot program locations our total enrollment was 55 patients. You’ll notice that there’s
a column for attrition and this is based on the
metrics that we determined to accommodate for those
that were identified as being, patients with white-coat hypertension. And so you can see that they’re were a significant number who
presented to the clinic with an elevated blood pressure that once they were evaluated
for a week at home and returned with those
blood pressure logs that they were identified as having normal blood pressure once
they returned for followup. So that left a total of
34 who warranted treatment or intervention, and out of those 34, 17 patients demonstrated
a blood pressure reading less than 140 over 90 at
the followup appointment. I have additional patients
with a blood pressure reading still over 140 over 90, still demonstrated a lower blood pressure in comparison with the
initial blood pressure at the time of enrollment. So that indicated a 64% of those patients who qualified for treatment,
that showed an improvement in the blood pressure readings
at the followup appointments. You’ll also notice there
are two columns there, the two columns to the right, those patients were still being monitored at the end of the actual program, and were still in the one month and three month followup phase. So the remaining six locations there was a total of
166 patients that were enrolled in the program. 99 of those were again identified with white-coat hypertension. And of the remaining 67,
24 patients demonstrated a blood pressure reading
less than 140 over 90 on a followup appointment. And 13 additional patients, although they had blood
pressures over 140 over 90, they demonstrated lower blood
pressure on the followup in comparison to their initial
enrollment blood pressure. So an overall improvement
of 55% in those patients who had qualified for treatment had improved readings at
all of the appointments. The project barriers and
successes that we noted. One of the barriers that we had, that there was varied
provider and staff engagement across all locations. And you may notice from the previous slide I’ll just go back. Oh maybe, there we go. The third location, location three had had quite an enrollment, but also quite a level of attrition. And so, you know that was a location that was very plugged in from the top to the bottom. And they were very, very anxious to find those patients that did have some, to determine whether they
had white-coat hypertension versus truly a diagnosis of hypertension. Also there were some data limitations. We thought about the
potential of being able to pull a list of patients who
may have had more than one blood pressure that was
elevated 140 over 90. And our EMR did not have
that ability to do that. It would identify those who had one, at least one blood pressure
of over 140 over 90. But it couldn’t determine, the programming was such
that it couldn’t determine, to narrow that down those that
had had two blood pressures of 140 over 90. So that was why our focus
was at the point of care. And we felt that that was successful and really the place
where the intervention needed to take place, knowing that those, the
patients would eventually come in and again be
identified at that time. I feel like our successes
were patient engagement definitely the improvement
in blood pressure rates indicated that
on the previous slides. Also clinical staff skill improvement. An interesting note was that for one payer program we
did have a 9% improvement in controlled blood pressure
within a four week period of rolling this out. And so that to us was a success. I feel that, it was more, not a
diagnosis, not finding those that needed to be diagnosed
with hypertension, but correct techniques that were, the staff were using
to be able to determine whether or not this was
truly a patient with, that needed to be
evaluated a little further. One of the successes we
feel were the provider and staff engagement and you’ll notice that I listed that as a barrier as well. Because at certain locations this was also a success while
in others it was a barrier. As well our project
planning, implementation and management, that’s a success as well. The framework for this project will allow, is going to allow us to be able to push additional projects into our clinics and be successful at that. We are extremely happy
that we were awarded the 2016 HealthInsight Innovation Award, as a result of this project. We recognize that success and celebrated that with our clinics. So beyond the initial project,
project sustainability, we have continued our ongoing staff education. And we’ve incorporated that
into our new hire process, so everyone is at the same,
on the same playing field. They know exactly what the expectation is and understand how to
identify those who present with an elevated blood pressure. Ogden clinic now supplies each location with a blood pressure
patient education booklets that were initially funded
with the grant money. And the blood pressure monitors continue to be utilized at all
family medicine locations. We discontinued reporting
at a location level and having those conference calls, but the project continues. Just individually at each
clinic and the results continue to be evaluated
at an organization level with the NQF-18 measure. So lessons learned, I would
say the biggest lesson that we’ve learned from this is to plan the project, not the process. We thought we were, we had it figured out, that the process would be identify, educate, evaluate and graduate. And it just didn’t work to
just make that statement and say that that was gonna work. So we really had to take a step back between phase one and phase two. And really roll out
the project completely, so that everyone knew
what they’re roll was in the success of the project
in identifying those patients. And that’s really where the
project became successful as well as when we had that
accountability in place. Also lessons learned, it was to involve key stakeholders in all
phases of the project. We did this initially. And this proved to be beneficial because the boots on the ground
are actually the ones that can poke the holes in the project and find the things that are gonna go wrong with it before
you’ve rolled it out and found that things went wrong. We did make adjustments along the way and that was very successful. A couple of adjustments
that we needed to make, we recognized early on that we did not have a Spanish version of our education. So that was adjusted. We also added ways to
prevent blood pressure. So we felt that was
important to incorporate. And that was an initial mission. We also added large blood pressure cuffs
as part of the project. And then each of the
locations found that it was, it was difficult to maybe get
that knowledge transferred from the MA, and identifying those patients who had an elevated blood pressure
that was in the room. Sometimes the provider would
come in right afterwards and they would just go on the visit and not recognize that that was something that was a factor, regardless
of whether they were there for that purpose or for just a simple sinus infection. So we developed some
magnets that we put on the outside of the doors
and that became our method of having the staff members identify to the provider that this was a patient that they needed to be aware that they had an elevated blood pressure. Also lesson learned was to maintaining the regular communication
with those who were managing the project at each location. This really, this
touchpoint every two weeks and then we back off to every month, as the project rolled out. Made it so there was some accountability and it allowed those
that were participating at other locations to
share what was working and what wasn’t. And that really became a
big part of that project. We also recognized the need
to maintain forward motion midway through the
project and finish strong. So we rolled it out strongly at the first and then about midway
through we took the project back out to each of the locations at the staff meetings and
repromoted the project. And recognized them for the success that they had
already achieved halfway through the project and still promoted that project continually. And then as always it’s
important to recognize the efforts of the staff members who were effectively implementing the project and making a difference
in our patient’s lives. And we really had some
success at our locations with this project and we
appreciate the opportunity to participate in that, in
those projects, thank you. – [Rebecca] Excellent, thank you. And we do have some questions
coming in, so we’ll, we’ll have Jaime go through her slides and then we’ll get to those questions. Everyone’s curious about monitors, which I knew would be a big question, every one always is. If you want to pass the keyboard to Jaime she can advance her slides. Thank you Carrie. – So I’m Jaime Fitzgerald. I currently work at Exodus Healthcare which has two locations
here in Salt Lake City, one in Magna and one in West Valley. Our program is a little less refined and we’re still in the process
of really refining that and getting it going as I am a part of multiple programs we have running in our clinics. Ours is ongoing, very baby
steps, I guess I would say in regards to Carrie. It’s just been nice
even listening to Carrie in regards to what they’re
doing in their programs. Hopefully have a little bit
of helpful information for you in regards to this program
that we implemented. So improvement opportunities. When I came on staff,
they never had a nurse on staff before, so my role
was undefined at that point. So when I stepped in I kind
of looked at opportunities that I could possibly engage
in or get up and running when I first started at Exodus. The big thing was having a
champion for this program. The need to see what
our practice values were in regards to hypertension and then recognizing the
need for improvement. And then just looking at
our current management of hypertension, we were part of the Million
Hearts incentive in 2014. Which brought attention to current hypertension practices in our clinic. And then we also participated
in the Million Hearts, and we received gold status which– – [Rebecca] Jaime, I’ll just jump in, this is Rebecca in Utah. This is something that
the Utah coalition does. So if you’re in another
state that you might be wondering what that is, that’s something kind of specific to the
coalition here in Utah. – And then our goal as a
clinic now is to work towards platinum status, which again would just create that opportunity
to really refine this program and our hypertension practices. Then consistency across
the practice was something that we noticed right away. We are a smaller practice. We have 80 staff members
and we currently have 16 providers between the two practices. So we really want to focus on MA practice, provider practices and
then the patient education portion of that in self management. Quality Management
Report is where I started when I first came on. Our quality management team
is still also being refined and again, we’re still just moving along in regards to getting that really rolling well, so. We’re just a very small team. So this report here is
just the most recent report that I pulled in regards. We’re a part of the ACO
here in Salt Lake City. And these are just our
current, most current numbers that just show a hypertension
control rate for 140 over 90 is satisfied so those patient’s blood pressure is below 140 over 90. And then you can see this
55% of those patients that are uncontrolled. And that’s with 1,019 patients. Then for our 60 plus
years we had 117 patients, 58% of the control rate of
the 150 over 90 satisfied. And then you can see there’s
41% that are unsatisfied. So this is just a great
picture to see that we can really improve on our current practices and what we’re doing. Change process. I think the first thing I
recognized when I came on was just the stages of behavior to change. It takes much longer
than I originally thought it would take to implement
something that seems so small and straight forward,
it’s a lot more complicated. And so this was a really
big thing in the beginning just to realize that process. Again staffing champion
is really important, you have that person that is just over it. My next goal would be
to bring on an assistant down the road, to help me with those calls as I work in different
areas within that clinic. Monthly meetings regarding
the clinic and just where we’re heading and making
sure that we’re on point and we’re heading in the direction that we desire to go. And then continued development
which I said earlier on. Management of hypertension the patient. So currently we do group meetings. And then we do one on one which I do with patients for education. Then we pull quarterly
ENR reports currently. And then from there we do, we do patient calls to those patients whose blood pressure are over 140 over 90. And then 150 over 90 for
our 60 plus patients. Ongoing training for
our MAs and providers. We’re currently using
the JNC-8 guidelines. And then since I started this program I put in some policy and procedures. So there wasn’t anything
in place in the beginning, so we really started from the ground up. Change process. Again we’re moving towards
that Million Hearts platinum status which
means this really has to be refined what we’re doing and consistency across the board. We actually teach all of our staff about programs that we
implement from our billing to scheduling to front desk staff. So they’re all so aware they
can pick up on those patients if anything should come up. The picture on the right hand there is a card that we produced once we started this program,
the dos and the don’ts with blood pressure, which
also helps our patients when they come back into our clinic to realize when it’s not being done right. So again that’s self management. It’s just being really important, we’ve got
feedback from our MA team that patients have said,
“I need to be quiet,” or “I can’t talk,” or, “I
need to be left alone “for that five minutes.” So just teaching the patient, we seen some successes with that. On the back of this sheet here you can see we have the patient’s
current blood pressure, the medications they’re on
and followup appointments. So with the training, just access to the home
blood pressure monitoring. I started out with our
MAs and our providers. We have a folder that
has all the information that’s needed to get to that patient. We have a PowerPoint presentation that we give those patients and then other literature that
goes along with that. We also have the 24 hour
blood pressure monitoring program in place as well and that’s done with one of our provider champions that I work alongside with. And he does the training
and that and he sets it up with the providers independently. So home blood pressure
monitoring procedure. So the patient is identified
for home monitoring by their PCP. Unless I implement the quarterly
calls that we implement. Again I am one person, so I don’t get all those calls on a quarterly basis. So we are reviewing
getting me an assistant to help out with those calls. The patient will meet with
me once they’re identified. And I’ll sit down with them, I’ll come in and then we’ll go through the PowerPoint, we go through lifestyle changes that need to be
made, their medications clear up any areas that
they don’t understand how the medications work. They show them how to use the
home blood pressure monitor. This is one of the ones
that we currently use in the little casing. Each casing has a little
tag on it with a number on the monitor. And then we have the patient sign, the equipment responsibility, if they damage it
outside of normal damage, but these are the ones we currently use and we also use a Welch Allyn
monitoring system as well. That connects to the patient’s phone. And the doctor can go
in and log into that, to Welch Allyn and they can look at their readings right there and then. And then the patient will be sent home with that blood pressure monitor. Most of them are sent
with them for two weeks. But again that can be
decided with their PCP and how they want to move forward of how long they want them to have it for. And then the patient
will return for followup with the PCP. And then I’m a part of the provider team, so they keep me on board as long as they need me on board. We walk through with that
patient ’til they have the successes that they’re desiring. So it’s definitely a team effort. Outcomes, the white-coat
syndrome eliminated. Constant observation and diary helps determine patient’s needs. Patient medication regime. We will increase the current dosage, additional medication added, or the current medication
regime is appropriate. So it just eliminates
some of those guessing moments that doctors possibly have in that short amount of time that they get to spend with their patients. And then just a team approach
has positive patient outcomes. Program maintenance again
that having a champion is absolutely needed. Just keep everything moving. And then continuous
feedback and remainders to staff regarding the home blood pressure monitoring services. This is really big. I’ve found in our clinic
is just there’s so much that’s being asked about
MAs, about providers. As you know (mumbles) is
supposed to be changing. So just that constant
feedback and reminder, I’m kind of that little nagging person in the background. (laughs) So it’s really helped them. Our staff will always
come up and share with me that they’ve given out a monitor, or they’ve set up appointments. And so it’s just those
gentle reminders throughout and that consistency overall that’s been hugely beneficial. So I did it through it emails, I attend staff meetings and I continue to go over the different programs that I’ve implemented in our clinic. And then I do one on one
with new staff members when they come on board. And then again patient
outreach via our EMR and then quality reports pulled. Lessons learned, again the champion. Consistency, training, a budget is needed to implement the program
because of my time. And then possibly
bringing on an assistant. And then just hypertension
control rates did change when we initially started
this program back in 2014 when I first came on, when we started with the Million Hearts. It was about a year into
that that we implemented the home blood pressure program and providers did see
changes and they feel like it’s very beneficial. And then just more accurate, more accurate treatment. Just as Dr. Stults was saying, just that need for home
blood pressure monitoring is so vital to the big
picture of the patient. And then providers feedback has just seen the benefits of that team
approach to patient education and their role in self
management practices. Getting the patient on board is key. The patient’s gonna want it more than we want it for them. Yeah. That’s it. – Bram Stoker is the
guy that wrote Dracula. (everyone laughs) That’s the person that wrote Dracula, did you say that?
(everyone laughing) – That’s funny.
– You’re a coot. – [Rebecca] Thank you
Jaime that was great. Well we knew this would be a packed hour with just lots and lots
of great information and things to think about
and things to implement. And we have about four
minutes left for questions. So please chat some in. And/or come off of mute. I’ll pause for a second
if you want to come off of mute and ask a question. – [Edie] We did have one in the chat that came up earlier about blood pressure monitors at clinics. Who paid for those monitors? And were the monitors robotic? – [Rebecca] Robotic. – So they were automatic
cuffs that were purchased. And the, one of our
grants that we received we used for that, the purchase of those blood pressure cuffs. And then from now on that’s gonna be the maintenance of those
and replacement will be something that the clinics will be purchasing and up keeping. – [Edie] And for those
participants in Utah, Kelly Robinson from the
State Department of Health, who runs the Million Hearts coalition was looking, they assisted with a grant and they’re currently
looking for resources for SMBP monitors. And gave her contact
information in the chat for those of you in Utah. Unfortunately she didn’t
have any information if there’s anything like
that in other states, but to contact each state’s
department of health. – [Rebecca] Thank you Edie. Anyone have a question? Do you have questions for each other? (everyone laughs) Yeah you’ve had some great successes and we would love to
continue this conversation next month, in January and
actually I’ll just advance here to, so you can see the
date of our next webinar. On January 24th. And if there’s something
you want to hear more about, please chat that in or let us know. But we want to know, you know what you’re
doing in your setting. We want to know if you’re implementing some home blood pressure
monitoring programs, we want to know what your barriers are, what your successes because there’s a wealth of
knowledge on this call today. I’m sure that various
people on the call have done similar things
and you all have things to share with each other. We want to check in in January
and see what you’ve had a chance to do and, kind of problem solve and
trouble shoot with each other. And hear what you think
about the new guidelines and what your clinic thinks. Have you guys had that
conversation at your clinics yet about the new guidelines? – We have. – [Rebecca] And what did you decide? – Our family medicine
doctors are on the fence and kind of taking the same role as AAFP at this point, so. – [Rebecca] Yes, yeah kind of a watch and see.
– Watch and see, yup. – [Rebecca] If anything,
that’s the approach a lot of people are taking right now, is kind of a wait and see. But thank you for joining us today The information was incredible. And I think participants
gained a lot from it. If you have questions
and you’re on the line and you want to chat those in, please do. We’ll keep the webinar open
for a few more minutes, so that you can chat some questions in. We’ll gather those up
and see if our presenters can address them either offline or on the webinar next month. Again like I said, Wednesday January 24th is when we’ll be doing that again. There is a post webinar survey that we will ask you to complete. And that is, the link
to that is in the chat, so it’s easily accessible for you there. And thank you for joining. Have a nice holiday season, everybody. I think it’ll be interesting
what questions come in.

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