Jerry Penso, MD, MBA – Chief Quality and Medical Officer at the American Medical Group Association

Medical professionals have known about the risks of poorly controlled hypertension for over a century and effective treatments have been available for more than 50 years. Yet according to the Centres for Disease Control and Prevention, less than half of the 68 million American adults with hypertension have their condition under control, and nearly 20 percent are unaware they have it.

Blood pressure control has been challenging mainly because it is a “silent” condition in terms of physical symptoms. For this reason, patients may not adhere to recommended medication or lifestyle regimens, physicians may not treat hypertension as an urgent issue, and the disease may not get the public attention that other diseases receive.

Our current health system is also primarily designed to address acute medical problems, not chronic conditions that require team-based, longitudinal care with advanced information technology and patient-centred care.

To address hypertension and other pressing chronic conditions, the American Medical Group Foundation (the non-profit research arm of the American Medical Group Association) has launched a multi-year initiative, the Chronic Care Challenge. This program leverages best practices in disease management and population health. Measure Up/Pressure Down, the program’s first campaign brings together nearly 150 medical groups and health systems to achieve a goal of 80 percent of patients in control of their high blood pressure by 2016.

Groups across the nation, including Cleveland Clinic, Geisinger Health System, Kaiser Permanente and Mayo Clinic, are implementing up to eight evidence-based care processes that were developed by the campaign to achieve this aim. These processes have been proven to work in healthcare settings and have resulted in successful improvement rates among groups.

Medical practices and health systems of all sizes can easily implement these campaign strategies to identify and engage hypertensive patients. Following are some of the methods that Measure Up/Pressure Down’s participating medical groups around the country are using to improve control rates among their patients:

1. Retrain direct care staff in accurate blood pressure measurements

Studies show that every day, hundreds of patients with hypertension visit their doctor’s office and leave without having the disease diagnosed or addressed. To properly identify hypertensive patients, direct care staff must be trained in accurate blood pressure measurement. This training, as well as annual certifications, should cover techniques for patient positioning, selection of cuff size, obtaining a valid blood pressure measurement, recording it accurately and reporting abnormal results. For example, Cornerstone Health Care in North Carolina has developed two training videos to demonstrate the differences between accurate and inaccurate techniques for its team members. Additional topics to address during training sessions may include knowledge of proper techniques and different types of observer biases, processes to properly maintain and calibrate equipment, and interpretation of measurements including an understanding of the variability of blood pressure depending on the time of day, exercise and timing of medications.

2. Keep track and reach the patients most in need of care

Effective care for chronic illness is virtually impossible without information systems that ensure ready access to key data on individual patients as well as populations of patients. A comprehensive clinical registry can enhance the care of individual patients by providing timely reminders for needed services, with summarized data used to track and plan care. At the practice level, a registry can identify groups of patients needing additional care and facilitate performance monitoring. Populated with electronic health records (EHRs), registries can provide: patient lists for specific conditions; decision support tools at the point of care to make providers aware of a patient’s hypertensive status and recommended care; exemption reports to identify hypertensive patients not meeting management goals which can be used to drive patient outreach efforts; and progress reports examining provider, staff and site performance.

Summit Medical Group, a physician-owned multispecialty practice in New Jersey, uses its EHR to develop these patient lists. On a monthly basis, color-coded lists are disseminated internally to indicate the blood pressure control of individual patients. Physicians and staff use these documents to conduct targeted outreach, schedule screenings, and appointments and re-engage patients in their care.

3. Begin engagement from the office door

Office visits provide multiple opportunities to educate patients about hypertension. Practices participating in the Measure Up/Pressure Down campaign incorporate blood pressure control into each of these patient encounters:

Check-in. As patients update medical records and insurance information, they also fill out a questionnaire to help identify blood pressure knowledge, goals and barriers that can inform the provider-patient conversation.

Waiting room. Educational materials in the waiting room cover topics related to blood pressure including lifestyle changes and medication adherence. Many groups also broadcast blood pressure-specific videos and public service announcements on waiting room televisions, while others display educational resources, like the Measure Up/Pressure Down Circulation Nation: Your Roadmap to Managing High Blood Pressure patient booklet.

Exam room. Some practices, such as Colorado Springs Health Partners and University of Utah Health Care, display posters near blood pressure cuffs that showcase accurate measurement. These signs help patients understand the rationale for staff requests (e.g., if a patient doesn’t remove a jacket as requested, their blood pressure measurement will fluctuate by 10-40 mmHg), remind staff the importance of accurate measurements and empower patients to take an active role in their own health.

Post-exam. Research suggests patients may understand and retain only half of the information discussed with a provider. Groups often provide customized materials to help patients understand and share this health information. For example, patients at Billings Clinic receive the “Your Blood Pressure Report Card” at each visit, which includes highlighted patient data from the EHR (including recent blood pressure readings, arm circumference, and weight measurements) as well as lifestyle goals and actionable tips.

4. Engage patients outside the office

The true test of engagement and adherence is when patients leave the doctor’s office and manage their conditions on their own. It is crucial to first determine the extent to which individual patients understand hypertension and how involved they want to be in their self-management.

For patients who are willing and able to plan and take action, practices and groups have implemented:

Home blood pressure monitoring. ThedaCare Physicians, a community health system in Wisconsin, equips patients with free home blood pressure monitors. Patients learn tips for accurate readings, measure and record blood pressure on a regular basis and share results with their provider for medication adjustments or lifestyle changes. California-based Arch Health Partners provides its patients with a wallet-sized tracking card to record readings.

Health coaches. In Iowa, Mercy Clinics, Inc. embedded health nurses into the system to work with diabetic patients (many with hypertension). Guided by patient data and chart review, coaches reached out to those with poor hypertension control and helped them manage their conditions with food diaries and one-on-one motivational coaching.

Mobile apps. Marshfield Clinic Research Foundation in Wisconsin developed the Heart Health Mobile app, which provides a quick heart health check, motivates users to obtain a more accurate assessment with blood pressure and cholesterol values and directs users to nearby locations offering affordable, convenient blood pressure screenings.

Learn more about these evidence-based care processes, and discover what medical groups and health systems are doing to achieve progress in improving hypertension rates from their success stories.  In addition, all tools mentioned here are available for free in the Measure Up/Pressure Down Provider Toolkit.

Jerry Penso, MD, MBA, is chief quality and medical officer at the American Medical Group Association. He oversees quality initiatives through the American Medical Group Foundation, a 501(c)3 nonprofit, including best practices in care collaborative and the Chronic Care Challenge. Follow the campaign at @MUPDcampaign.

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