ENHANCED COMPONENT

Increase implementation of quality improvement processes in health systems

Increase electronic health records (EHR) adoption and the use of health information technology (HIT) to improve performance
Increase the institutionalization and monitoring of aggregated/standardized quality measures at the provider and systems level

Short-term Performance Measures

Proportion of health care systems with EHRs appropriate for treating patients with high blood pressure and patients with diabetes
Proportion of patients that are in health systems that have EHRs appropriate for treating people with high blood pressure and patients with diabetes
Proportion of health care systems reporting on NQF18
Proportion of health care systems reporting on NQF 59

Intermediate Performance Measures

Proportion of adults with high blood pressure and patients with diabetes in adherence to medication regimens
Proportion of patients with high blood pressure that have a self-management plan (may include medication adherence, self-monitoring of blood pressure levels, increased consumption of nutritious food and beverages, increased physical activity, maintaining medical appointments

Long Term Performance Measures

Proportion of adults with known high blood pressure who have achieved blood pressure control
Decreased proportion of people with diabetes with A1C >9
Age-adjusted hospital discharge rate for diabetes as any-listed diagnosis per 1,000 persons with diabetes

Enhanced Component Public Health Strategies

Support the health systems by offering to convene and/or participate in continuing education trainings for health care providers. Training topics may include:
Population health – At a state level and health system level.
Use of health IT and registries to manage patient care and improve quality of care. For example, encourage providers to routinely review population of patients with hypertension. Identify those who have not been seen in the last six months and schedule them for a planned-care hypertension visit.
Use of clinical decision supports and clinical protocols. Train all members of health care team on the application and benefit of these clinical tools.
How to utilize the health care team to their full potential to improve the management of hypertension patients. Nursing staff can provide care management, behavioral health staff can support patients in overcoming barriers to self-management, and medical assistant staff can oversee patient reminders and follow up appointments.
Implement protocols to monitor hypertension patient medication adherence. Utilize members of the health care team including those in community such as community pharmacists.
Promote the use of evidence-based practices and encourage health systems to implement standardized, guideline-based treatment protocols.
Partner with other organization in your state such as RECs, QIO, ACO and PCMH initiatives to convene or participate in ongoing learning collaboratives.
Become familiar with evidenced-based quality improvement methods and tools such the Model for Improvement and Plan-Do-Study-Act (PDSA). Encourage health systems to use these models. You can explore these quality improvement tools under the Resources and Links section of this website.
Encourage health systems/health care providers to engage and include patients who have hypertension on their quality improvement team.
Go to Health IT Dashboard to get an overview of Health IT adoption in your state.
Locate the Regional Extension Center (REC) in your state.
Convene a meeting with key stakeholders, such as your local REC provider and local QIO to discuss current electronic health record prevalence and data retrieval/exchange.
Identify healthcare providers/systems who have an electronic health record (EHR)
Share information about national initiatives to promote EHR use such as Meaningful use
Share information regarding successful initiatives such as the NorthShore University Health System (DeGaspari J. The 2013 Healthcare Informatics Innovator Awards: First Place Winner: NorthShore University HealthSystem).
Share tools to assist in chronic care management such as blood pressure and/or diabetes algorithms.
Discuss health systems hypertension and/or diabetes prevalence compared to state and national averages. If needed, strategize action steps to improve outcomes.

Increase use of team-based care in health systems

Increase engagement of non-physician team members (i.e., nurses, pharmacists, and patient navigators) in hypertension (HTN) and diabetes management in health care systems

Short-term Performance Measures

Proportion of health care systems with policies or systems to encourage a multi-disciplinary team approach to blood pressure and A1C control
Proportion of patients that are in health care systems that have policies or systems to encourage a multi-disciplinary approach to blood pressure and A1C control

Intermediate Performance Measures

Proportion of adults with high blood pressure and patients with diabetes in adherence to medication regimens
Proportion of patients with high blood pressure that have a self-management plan (may include medication adherence, self-monitoring of blood pressure levels, increased consumption of nutritious food and beverages, increased physical activity, maintaining medical appointments

Long Term Performance Measures

Proportion of adults with known high blood pressure who have achieved blood pressure control
Decreased proportion of people with diabetes with A1C >9
Age-adjusted hospital discharge rate for diabetes as any-listed diagnosis per 1,000 persons with diabetes

Increase use of self-measured blood pressure monitoring tied with clinical support

Short-term Performance Measures

Proportion of health care systems with policies or systems to encourage patient self-management of high blood pressure
Proportion of patients that are in health care systems that have policies or systems to encourage patient self-management of high blood pressure

Intermediate Performance Measures

Proportion of adults with high blood pressure and patients with diabetes in adherence to medication regimens
Proportion of patients with high blood pressure that have a self-management plan (may include medication adherence, self-monitoring of blood pressure levels, increased consumption of nutritious food and beverages, increased physical activity, maintaining medical appointments

Long Term Performance Measures

Proportion of adults with known high blood pressure who have achieved blood pressure control
Decreased proportion of people with diabetes with A1C >9
Age-adjusted hospital discharge rate for diabetes as any-listed diagnosis per 1,000 persons with diabetes

Enhanced Component Public Health Strategies

Assist organizations in assessing and implementing changes in practice through the use of expanded primary care models, such as; patient centered medical home, community care teams, and community health workers.
Be a convener to sponsor health system/provider education for implementing team-based care models.
Review the National/State initiatives and Healthcare Models section of this website to learn more about existing/successful team-based care implementation.
Review the Resource section on this website for articles and tools related to team-based care.
Encourage and support healthcare systems and pharmacy partnerships. There are national initiatives such as, “Team Up/Pressure Down”, a Million HeartsĀ® initiative.
Go to the Resource section of the website under Tools-Team-Based Care to review the Program Guide for Public Health, Partnering with Pharmacists in the Prevention and Control of Chronic Disease .
Convene a meeting with key stakeholders, such as your state/regional Quality Improvement Organization, Primary Care Association, Local retail Pharmacist, Local primary care leader (physician or non-physician such as Nurse Practitioner or Physician Assistant), and RN/Case Manager, to discuss methods of team-based care. Explore possible lines of communication and the exchange of health related information amongst mutual patients.
Promote efforts to involve community health workers (CHW) as part of team-based care. This may include conducting an environmental scan CHW programs in your state or connect with states with existing CHW programs.