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Finger Lakes Health Systems Agency

Engaging a Community in Change:The FLHSA/RBA

High Blood Pressure Collaborative

P2 Collaborative of Western New YorkO t b 13 2011

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October 13, 2011

Al BradleyProgram Manager

Finger Lakes Health Systems Agency

Vision: A local health‐care system that makes people healthier and saves money, by delivering the right care, in the right place, and at the right time 

FLHSA: Vision, Mission & Strategy

for everyone in the community.

Mission:We are an independent organization working to improve health care in Rochester and the Finger Lakes region, by analyzing the needs of the community, bringing together stakeholders and organizations to solve health problems, and measuring results.

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Rochester Business Alliance Health Care Planning Team

• RBAHCPT began meeting in 2005 to increase the value of care delivered in the regionof care delivered in the region

• Initial focus on increased hospital efficiency, increased use of generics, support the Rochester RHIO, expand Eat Well Live Well

• Decided on need to encourage more effective and efficient care of chronic diseasesRecognized the need to confront disparities and identify• Recognized the need to confront disparities and identify those at greatest risk of adverse outcomes

• Partnered with FLHSA to take advantage of its community reach

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Why High Blood Pressure?

• High blood pressure affects 65 million AmericansIn NYS: 27.2% have a diagnosis of high blood pressure; Aggregate annual spending is $1.1 Billion

In the Finger Lakes Region: 29.4% (237,200 adults) have this dx; Aggregate spending is $305 Million

Monroe County estimate – 170,000 adults have high blood pressure

• Affects more than half the people age 60-69; and 64% of males and 78% of females 80 and older have HBP

• African Americans have 1.5-2 times higher incidence of high blood g gpressure; Latinos have an incidence 1.4 times the non-Latino White population

• For every 20 mmHg systolic or 10 mmHg diastolic increase in blood pressure ,mortality from both ischemic heart disease and stroke doubles

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Why High Blood Pressure?

• There is room to improve care:– 30% of the population has pre-hypertension with

increased risk of cardiovascular disease (BP 130-increased risk of cardiovascular disease (BP 130-139/80-89)

– 29% of those with elevated blood pressure don’t know it!

– 39% of those diagnosed are not receiving therapy– For patients age 45-84, only 65% of patients

i d h t i h th i bl drecognized as hypertensive have their blood pressure controlled

Cutler et al. Hypertension. 2008;52:818

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Morbidity of HBP

• HBP contributes to the rates of HF, MI, Stroke and need for Dialysis

• Admissions for these four conditions account for over• Admissions for these four conditions account for over $90,000,000 yearly in Monroe County

• Those at most risk for these complications are the elderly, minorities and the socioeconomically disadvantaged

• Lowering blood pressure to less than 140/90 reduces these complicationsthese complications

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Does Treatment Work?

• Optimizing blood pressure control would be expected to:– reduce stroke incidence by 35-40%– reduce heart attack incidence by 20-25%– reduce incidence of heart failure by 50%

Chobanian AV. NEJM 2009;361:880

• In patients over 80, active treatment was associated with:- a 21% reduction in the relative risk of death - a 64% reduction in the rate of heart failure- a 39% reduction in the rate of death from stroke- a 30% reduction in the rate of non-fatal stroke

Becket NS. NEJM. 2008;358:1

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Overriding Goals

• Goal 1 – Reduce the number of admissions for stroke, heart attack, coronary disease and the initiation of dialysis by 5% per year between 2011 and 2014dialysis by 5% per year between 2011 and 2014

• Goal 2 – Reduce the cost per case per year of HBP in Monroe County by improving HBP evaluation and management

• Goal 3 – Improve to proportion of adults with hypertension who achieve goal blood pressure to 85% by 2014by 2014

Reduce disparities in the rate of these complications over the life of the project

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Objectives

• Create of a true community-wide effort to improve percent of patients achieving target BP

• Define the population in most need of improved BP• Define the population in most need of improved BP control

• Define desired health behaviors and implement experiments and strategies to achieve sustainable change

• Identify clinical inertia as a significant contributor to less than optimal BP control

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than optimal BP control• Solicit ideas of how benefit redesign might improve

clinical performance• Establish baselines and measures of success

Community OrgsEmployers

Health Systems/PlansOrganization of Health Care

Improving Health Outcomes For High Blood Pressure

Resources, PoliciesWellness PromotionConsumer Outreach

And Coaching

Self-Management Support

Delivery System Design

Decision Support

Clinical Information Systems

Informed Activated

Patients/Families

Prepared, Proactive Practice Teams

ProductiveInteractions

Quality and Value Outcomes; ROI; Engaged Satisfied Participants Wagner, E, Group Health

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To be Successful – What Would Wagner Do?

Increased Consumer and

Community Awareness

Using bestCommunity Support for Using best

evidence to improve care

Support for Seeking and

Maximizing Self Management

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Building the Collaborative

• RBA Healthcare Planning Team– Bausch + Lomb, FLHSA, Jasco Tools, Kodak, Paychex,

Rochester Institute of Technology, Wegmans, Xeroxgy g

• Finger Lakes Health Systems Agency– New York State DOH, Monroe County Health Department– African American Health Coalition– Latino Health Coalition– Over 1,000 engaged community stakeholders (aging, childhood

overweight & obesity, lead poisoning, HIV/AIDS …)

• Chair – Paul Speranza, Vice Chairman, General Counsel, and Secretary; Wegmans Food Markets, Inc.

• 100 participating stakeholders, 50 organizations, nine workgroups

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Increased Consumer and Community Awareness

• Communications Work Group– Chair: Dawn Borgeest-Chief Corporate Affairs Officer, United g p

Way of Greater Rochester• Surveys and interviews to assess awareness, knowledge and

attitudes on high blood pressure• Identify the key audiences• Implement a comprehensive, segmented marketing campaign• Build web capability• Monitor national developments and lessons• Leverage existing communication channels (insurers, companies,

churches, human services, community…)

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Community Support for Seeking and Maximizing Self Management

• Behavior Change Work Group– Chair: Nancy Bennett, MD – Director, University of Rochester

Center for Community Health• Research and recommend application of behavior change theories

to strategic initiatives• Evaluate strategies for consistency with behavior change science,

research and literature

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Community Support for Seeking and Maximizing Self Management

• Community Engagement Work Groupy g g p– Chair: Wade Norwood – Director of Community Engagement,

Finger Lakes Health Systems Agency• Implement demonstration projects in churches and community

based organizations using trained lay health advisers• Create network of high blood pressure ambassadors in a variety of

community settings• Build a network of community based screeners, educators and

advocates

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Community Support for Seeking and Maximizing Self Management

• Workplace Wellness Action Team/Demonstration ProjectsProjects– Co-Chairs:

Cynthia Reddeck-LiDestri – Vice President, Health and Wellness, LiDestri FoodsJake Flaitz- Director, Benefits and Human Capital, Paychex• Implement demonstration projects in companies of varied size and

demographics to test behavior change strategy with trained lay health advisershealth advisers

• Leverage existing corporate wellness strategies with area companies

• Strategize corporate wellness business case and initiatves with small and mid size companies

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Community Support for Seeking and Maximizing Self Management

• Plan Design Work Group– Co-Chairs:

Larry Becker, Director, Strategic Partnerships andLarry Becker, Director, Strategic Partnerships and Alliances, Xerox

Becky Lyons, Manager, Health Care Design, Wegmans– Evaluate elements of health plans that may serve as

barriers or enablers to desired health management behaviors

– Assess payment model alternatives to fee-for-service that promote outcomes

– Survey practitioners to understand their views on health plan barriers and enablers

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Using best evidence to improve care

• Best Practice Work GroupChair: Michael Nazar MD Vice President Primary Care and– Chair: Michael Nazar, MD – Vice-President, Primary Care and Community Service, Unity Health System

• Partner with three major health systems and urban health centers to create a community high blood pressure registry

• Drive quality improvement efforts in hospital system based primary care practices

• Incorporate academic detailing to identify best opportunities for system change and improvement

• Inform all other work groups on clinical best practice and evidence in high blood pressure risk, diagnosis and treatment

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Using best evidence to improve care

• Professional Education Work Group– Co-ChairsCo Chairs

John Bisognano, MD – Cardiologist, University of Rochester Medical CenterThomas Rocco, MD – Cardiologist, University of Rochester Medical Center, Veterans Administration

• Conduct CME programs using nationally recognized high blood pressure experts

• Leverage existing Grand Rounds and medical staff meetings toLeverage existing Grand Rounds and medical staff meetings to focus on high blood pressure performance and control

• Research and distribute most current high blood pressure literature

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Establish Baselines and Measure Success

• Metrics and Measures Work Group– Chair: James Sutton RPA-C Director Office of CommunityChair: James Sutton, RPA C, Director, Office of Community

Medicine, Rochester General Medical Group• Define project measures, specifications, data sources and reporting

schedules• Identify national, local and best practice benchmarks• Incorporate continuous quality improvement into analytical and

reporting processes• Manage dissemination of metrics and measures reporting

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Development and Sustainability

• Development and Sustainability Work GroupCo Chairs:– Co-Chairs:

Fran Weisberg – Executive Director, FLHSAPaul Speranza – Vice Chairman, General Counsel, and Secretary; Wegmans Food Markets, Inc.Jake Flaitz – Director Benefits and Human Capital, Paychex• Identify funding opportunities to assure sustainability• Pursue grants and partnerships through foundations and corporate

partners• Align collaborative stretegies with appropriate funders

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On Whom to Focus:On Whom to Focus: The RBA/FLHSA High

Blood Pressure Collaborative Baseline Data

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Conclusions: Kidney Failure

• Kidney Failure rates have been trending upward over the past three years

• The cost of dialysis for a year is ~$75,000y y $ ,• The cost to the Monroe County community for dialysis

yearly is in excess of $21,500,000• Those at risk of renal failure are:

– Elderly– African-Americans and Latinos– The most socially disadvantagedThe most socially disadvantaged– Disparities are increasing

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• Hospitalization rate for Stroke is marginally changed over the past five years

Conclusions: Stroke

over the past five years• Those most at risk are:

– Elderly– African-Americans and Latinos

• The disparity is increasing

– The most socio-economically disadvantagedTh di it i i i• The disparity is increasing

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• Admissions for Heart Failure are trending downward• Those most at risk are:

Conclusions: Heart Failure

– Elderly

– African-Americans and Latinos

– The most socio-economically disadvantaged

– The disparity is increasing– The disparity is increasing

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• The number of admissions for CAD are falling

Conclusions: Heart Attack

• The number of admissions for CAD are falling

• Those most at risk are:

– Elderly

– African-Americans and Latinos

The disparity is increasing

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Dashboard

Tier 1 Measures

Measure Baseline Target Source

Tier 1a Incidence of complications of high blood pressure

The incidence of heart attacks 514 per 100,000 SPARCS*The incidence of heart attacks 514 per 100,000 SPARCS

The incidence of stroke 316 per 100,000 SPARCS

The incidence of heart failure 424 per 100,000 SPARCS

The incidence of kidney failureNew dialysis starts per year

47 per 100,000 NYS Dialysis Registry

Tier 1b The cost of care of high blood pressure

The cost of care per patient per year for those diagnosed H lth Pl Cl iThe cost of care per patient per year for those diagnosedwith high blood pressure

Health Plan Claims

Tier 1c The control of high blood pressure

The percentage of adults with high blood pressure who arein control

64% 85% Community Registry

* Statewide Planning and Research Cooperative

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Patients with BP information56,870

Monroe County Population ≥18569,120

Patients ≥18 with Dx HBP seen in participating practices* in past 3 years

97,400

Monroe County Population ≥18 withHigh blood pressure diagnosis(30% based on national data)

170,740 est.

Patients with HBP not seen in participating* ti ithi t 3 56,870

New patients1st seen in last 6

months460

Dx HBPNo BP read in 13 months10% - 5,370

Dx HBPBP read Within

13 months90% - 51,040

BP ≥ 140/9037% - 18,640

BP < 140/9063% - 32,400

practices within past 3 years

Patients with HBP not seen

Not Available

Patients with HBP seen in non-participating practices –

no clinical or demographic dataNot Available

BP < 140/90Not

A il bl

BP ≥ 140/90Not

A il bl

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37% 18,640 63% 32,400Available Available

Community Engagement

Education &Lifestyle Support

Community Engagement

toFind, Educate & Encourage Care

Best Practice to

Recruit Practices with EMRs

Measure ofCommunity

Engagement Success

Practice Quality

ImprovementOpportunities

Measure of Best

Practice Success

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Conclusions

• Monroe County as a community is working to transform care of chronic disease, beginning with high blood pressure

• Business as a leading participant in the Monroe County collaborative has been crucial to success

• The collaborative is designed to be a quality improvement project and not a research or public reporting initiative

• Key stakeholders were anxious to meaningfully collaborate in a community wide QI effortcollaborate in a community wide QI effort

• Good data is imperative• We are anchored in our values of transparency, honesty

and respect

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Finger Lakes Health Systems Agency

The triangle represents our agency’s role as a fulcrum—the point on which a lever pivots—boosting the community’s health by leveraging the strengths of all stakeholders. The fulcrum is also a point of equilibrium, reflecting our ability to balance the needs of consumers, providers and payers on complex health matters. The inner triangle also evokes the Greek letter delta—used in medical and mathematical contexts to represent change—with a forward lean as we work with our community to achieve positive changes in health care.

Give me a lever long enough and a fulcrum on which to place it,

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and I shall move the world. —Archimedes

1150 University Avenue • Rochester, New York • 14607-1647585.461.3520 • www.FLHSA.org