1 telligen cardiac learning network anna astalas, mpa, rn, cphq illinois cardiac primary point of...

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Telligen Cardiac Learning NetworkAnna Astalas, MPA, RN, CPHQIllinois Cardiac Primary Point of Contact

This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, 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. 11SOW-IL-B1-5/2015-11035

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• Telligen: Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Colorado, Illinois and Iowa

Telligen QIN QIO

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• Quality Improvement Organization in Illinois– We are contracted with Medicare to provide technical assistance,

facilitation, and support services to IL healthcare providers AT NO COST– We are inviting 100 provider/practices and 200 HHAs to participate in a

Cardiac Learning and Action Network– We will focus on (and follow) the four Million Hearts® ABCS measures:

Aspirin therapy, when appropriate (PQRS #204) Blood pressure control (PQRS #236) Cholesterol management (PQRS #316) Smoking assessment and cessation counseling (PQRS #226)

Telligen QIN QIO

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Promoting Disease Management and Prevention of Cardiac Disease

• Partners:– Beneficiaries and Families, Partners and

Stakeholders, Providers, Practitioners, Clinics, Home Health Agencies

• Our shared goals:– Align with Million Hearts Initiative to prevent

one million heart attacks and strokes– Improve ABCS– Reduce health disparities

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• How Will Telligen Help? – QI process/plan to improve measures– Local/national benchmark cardiac reports for comparison– Assistance with analyzing data trends for QI– Staff and patient resources, tools and toolkits– Educational events (monthly recorded webinars, live conference, etc.)– Sharing best practices and network among healthcare peers– Current Medicare rules and regulations– Improve Star ratings– Help with workflow improvement, engaging patients, team-based care and overall

patient outcomes!

Benefits of Participating with Telligen

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• Assistance With Other Tasks– Diabetes– EHR/MU measures– PQRS measures– Value-Based Modifier– Immunizations

If interested, contact:anna.astalas@area-d.hcqis.org

(630)928-5832

Benefits (Continued)

IMPROVING HEALTH OUTCOMES: BLOOD PRESSURE

Donna Daniel, PhDDirector, Improving Health Outcomes

American Medical Association

Mike Rakotz, MDDirector, Chronic Disease Prevention

American Medical Association

Telligen Cardiac LANMay 26, 2015

A M.A.P. for improving blood pressure

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 8

Disclosures

Donna Daniel, PhDNo disclosures

Michael Rakotz, MDNo disclosures

Have a question?

Text it to 206-335-8154

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 9

What we hope to accomplish today

• Provide background on the AMA-Johns Hopkins collaboration

• Summarize a program to engage your leaders and staff in improvement

• Describe a framework for improving blood pressure control

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 10

Prototyping new tools and resourcesPartner: Johns Hopkins Medicine• Armstrong Institute for Patient Safety and Quality (Dr. Peter Pronovost)• Center to Eliminate Cardiovascular Health Disparities (Dr. Lisa Cooper)

Advisory group of national experts in HTN care

Patient and family advisory group

10 Diverse Practice Sites• From solo practitioner to multispecialty practice with 14 physicians • Diverse patient panels ranging from 95% African-American to 87%

Latino, 60% Medicaid to 55% Medicare

Feedback on a framework, tools and resources and curriculum

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 11

Patient involvement in program design• Advisory group charged with reviewing tools,

advising on how best to meet patient and family needs

• Suggest new ideas, help prioritize tool development

Emphasis on improving health equity• Tapped into expertise of Johns Hopkins Center to Eliminate Cardiovascular Health

Disparities• BP control performance reporting stratified by race/ethnicity

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 12

The M.A.P. frameworkMeasure blood pressure accurately

Act rapidly to manage uncontrolled hypertension

Partner with patients, families and communities to promote self-management

Actionable data Evidence-based tools Adaptive changeMonthly reports on blood pressure control rate, stratified by key patient demographics

A toolkit for implementing the M.A.P. framework: checklists, fact sheets, posters, audit tools, patient engagement tools, etc.

A simple model for promoting teamwork, communication and a culture of quality improvement

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Applying evidence to improve blood pressure control

Mike Rakotz, MD

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 14

Why controlling BP is important

Lewington S. et al. Age-specific relevance of usual blood pressure to vascular mortality The Lancet, 2002

Ischemic Heart Disease and

Stroke Mortality due to elevated blood pressure

1 Million Adults, 61 Prospective Studies

Ischemic Heart Disease Ischemic Stroke

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 15

Why controlling BP is important

• Morbidity and mortality due to cardiovascular diseases are directly related to BP.

• In people with hypertension and elevated BP, when BP is lowered there is less vascular damage to organs (kidneys, heart, eyes, brain).

• Treatment of high blood pressure lowers risk of cardiovascular disease and death.

Kaplan and Victor Kaplan’s Clinical Hypertension. 111th Edition. 2015

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 16

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 17

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Why measuring blood pressure accurately is important

• Each 1 mm Hg rise in blood pressure above normal reduces life expectancy by one year on average

• Even small changes in BP have significant impact on the health of patients

How does this impact clinicians in practice?

Braunwald Hypertension 2014

Summary report: National High Blood Pressure Education Program (NHBPEP)/NHLBI and AHA working meeting on blood pressure measurement. Bethesda: National Institutes of Health; 2002. Available at: http://www.nhlbi.nih.gov/health/prof/heart/hbp/bpmeasu.pdf

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Why measuring blood pressure accurately is important

We need accurate, reliable blood pressures to make strong clinical decisions.

Braunwald Hypertension 2014

Braunwald Hypertension 2014

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

What are the most accurate techniques for BP measurement?

• 24-Hour Ambulatory Blood Pressure Monitoring (ABPM)

• Self-Measured Blood Pressure (SMBP) monitoring (home blood pressure monitoring)– Occurs outside of clinical setting, eliminating white

coat effect

– Allows for multiple readings over time

– Provides asleep blood pressures (in the case ofABPM)

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

The most accurate techniques for BP measurement

Until these options are more available, we must effectively screen for and confirm elevated BPs in our practices or health centers

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 22

How many errors in BP measurement do you see?

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 23

How many errors in BP measurement do you see?

1. Back is not supported

2. Arm is not supported near heart level

3. Cuff is over sweatshirt

4. Legs are crossed

5. Legs are not both flat on the stool

6. She is talking

7. She is listening

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 24

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 25

Correct patient position for BP measurement

For screening BP measurement• Automated validated device • Sitting in a chair with back and arm supported (1)• Legs uncrossed, feet on the ground or a stool (2) • Cuff over a bare arm (3)• Correct Cuff Size• No talking or texting

If the screening BP is > 140/90 mm Hg, obtain confirmatory BP measurements

For confirmatory BP measurements, same as above, plus• Ensure patient has an empty bladder• Rest for at least 5 minutes • Obtain the average of at least 3 measurements

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Why use office BP measurement?

• Opportunity to obtain BPs

• Technology has improved measurement reliability (validated, automated machines less human error)

• Protocols improve standardization, reduce variability and errors, and can improve workflow efficiency

• Obtaining confirmatory measurements increases diagnostic accuracy and reduces misclassification

• By reducing errors and increasing reliability of BP measurement, clinicians are less likely to hesitate when initiating or escalating treatment (clinical inertia)

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 27

When screening patients for high blood pressure: Use a validated, automated device to measure BP Use the correct cuff size on a bare arm Ensure patient is positioned correctly

If BP is ≥140/90 mm Hg, obtain a confirmatory measurement: Repeat screening steps above Ensure patient has an empty bladder Ensure patient has rested quietly for at least five minutes Obtain the average of at least three BP measurements

Measure accurately checklist

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

How single-pill combination therapy can help

Handler. J Clin Hypertens.

2013;15:874

Single-pill combination therapy gets patients to goal more quickly by • Expediting escalation of therapy• Using fewer prescriptions

Non-adherence to medications, another barrier to achieving blood pressure control, is reduced with single-pill combinations

• Using single-pill combination therapy improves adherence rates 26% compared to non-combination medications

Bangalore et al The American Journal of Medicine (2007) 120, 713-719

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Most common factors contributinguncontrolled hypertension

1. Miss opportunities to treat a patient with a BP > 140/90• Fail to initiate or escalate therapy during an office visit

• Fail to stress frequent follow up until BP is controlled

2. Non-adherence to treatment plan• Usually due to not taking medications as instructed

C L I N I C A L I N E R T I A

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 30

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Factors leading to clinical inertia

CLINICIAN• Failure to initiate treatment

• Failure to titrate to goal

• Failure to recommend follow-up

• Failure to set clear goals

• Underestimating patient needs

• Failure to identify and manage comorbid conditions

• Not enough time

• Insufficient focus or emphasis on goal attainment

• Reactive rather than proactive

Adapted from Milani RC et al J Am Coll Cardiol. 2013; 62: 2185-2187

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Factors leading to clinical inertia

PATIENT• Medication side effects• Failure to take meds• Too many medications• Cost of medications• Denial of disease• Forgetfulness• Perception of low susceptibility

• Absence of symptoms • Poor communication• Mistrust of clinician• Mental illness• Low health literacy

Adapted from Milani RC et al J Am Coll Cardiol. 2013; 62: 2185-2187

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Factors leading to clinical inertia

HEALTH SYSTEM• Lack of clinical guideline• Lack of care coordination• No visit planning• Lack of decision support• Poor communication

between office staff• No disease registry• No active outreach

Adapted from Milani RC et al J Am Coll Cardiol. 2013; 62: 2185-2187

HIGHLAND RIDGE PRIMARY CARE

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Why standardized treatment protocols are important

In hypertensive patients with systolic BP >150 mm Hg, treatment delays are associated with an increased risk of acute cardiovascular events or death

• Delays in medication intensification >6 weeks

• Delays in follow-up appointments >10 weeks after medication intensification

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 35

If patient has BP ≥ 140/90 mm Hg confirmed:

Use an evidence-based protocol to guide treatment

Re-assess patient every 2–4 weeks until BP is controlled

When possible, prescribe single-pill combination therapy

Act rapidly checklist

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 36

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Use evidence-based communication strategies

• Engage patients to improve compliance with therapy

• When clinicians talk less and listen more, they can gain relevant information, including details that can help us determine a preferred treatment approach

• When patients use this kind of communication, they are more engaged/committed, and as a result, are more likely to adhere

• Using these communication techniques does not lengthen visits (it actually shortens them), especially if all practice staff are using them

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 38

STRATEGYBegin with open-ended questions about adherence, including recent medication useExplore reasons for possible non-adherence

Elicit patient views on options and priorities to customize a care plan for each patientRemain non-judgmental at all times

Use teach-back to ensure understanding of the care plan

Use evidence-based communication strategies

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 39

Why self-measured BP (SMBP) is clinically useful

Slide from the American Society of HTN 2014 Review Course

SMBP better predicts CV morbidity and mortality than office BPs

• Reduces variability and provides more reliable BP measurement

• Provides better assessment of hypertension control

• Empowers patients to self manage their HTN

• May improves medication adherence

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 40

Lifestyle changes for hypertensive patients

• Healthy diet, such as DASH diet

• Reduced sodium intake

• Weight loss

• Aerobic exercise

• Moderate alcohol consumption

• No smoking

Taking a pill to lower BP

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Impact of lifestyle changes for improving blood pressure in patients with HTN

LIFESTYLE CHANGE CAN LOWER SBP/DBP UP TO:DASH diet, compared with typical American diet 11.6/5.3 mm Hg

Reduce sodium intake by average of 1150 mg/d 4/2 mm Hg

Average weight loss of 11 lbs 4.4/3.6 mm Hg

40 minutes of moderate intensity aerobic physical activity, 3–4 times a week

5/4 mm Hg

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© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 42

To empower patients to control their blood pressure: Engage patients using evidence-based communication

strategies Help patients accurately self-measure BP Direct patients and families to resources that support

medication adherence and healthy lifestyles

Partner with patients, families and communities checklist

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 43

AMA-JHM IHO: BP program tools

Includes a set of tools to support each checklist “Measure accurately assessment” tool “Act rapidly assessment” tool “Partner with patients, families and communities assessment” tool Posters, flyers, fact sheets, audit tools and “self-measured blood

pressure” program guide

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved. 44

Adaptive change in ambulatory practice program (ACAP)

• Supports culture change necessary to implement and sustain the M.A.P. checklists

• Engages all clinical and non-clinical staff to take ownership in patient care

• Taps into the wisdom of all staff members to drive improvement efforts

• Improves teamwork and teamwork for better and consistent patient care

© 2015 American Medical Association and The Johns Hopkins University. All rights reserved.

Thank youAny questions?

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• Wednesday, May 27 at 12:00 PM EDT – “A Team Approach: Integrating tobacco dependence treatment into routine clinical practice”, Dr. Chad Morris, PhD – Register: https://cc.readytalk.com/r/3pf7g6vgxjxi&eom

• Friday, May 29 at 8:30 AM-2:00 PM CST - Go Red for Women Community Expo at the Great Hall, Union Station, 500 West Jackson, Chicago - FREE– Register: Contact the AHA at 312-476-6679 or

GoRedChicago@heart.org• Tuesday, June 23 at 11:30A - Home Health Cardiac Kick-off: Get

Started with Cardiac Data!

Announcements

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• Would you like Telligen to provide additional information and webinars (or podcasts) on the M.A.P. BP program?

• Help us improve – please complete the survey• If not registered…. COME JOIN US! http://www.telligenqio.org/initiatives#cardiachealth

Contactanna.astalas@area-d.hcqis.org

(630)928-5832

Conclusion