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Pumping HHQI’sPumping HHQI s Cardiovascular Health Into ActionCindy Sun, MSN, RN, COS‐CCrystal Welch, MSN, RNMisty Kevech, MSN, RN, COS‐C

Objectives

Describe the overarching purpose of both HHQI and the Million Hearts® initiative HHQI and the Million Hearts initiative

Identify three (3) key tools from either of the two (2) Cardiovascular Health Best Practice Intervention Packages (BPIPs) that may be appropriate for your agency

Develop two (2) new methods of education to integrate cardiovascular health into your practices

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What is HHQI?Goal: Improve the quality of 

care home health patients receive

Special Project funded by Centers for Medicare & Medicaid Services

Free evidence‐based tools and resource

Many networking opportunities with 11,000 participants

Phase 3: September 2012 ‒ July 2014Focusing on quality of home health care measured by :  

• Reduction of avoidable ACH I i l di i• Improvement in oral medication management

• Improvement of immunization rates• Improvement of cardiovascular health

Continuing HH focus, but all care settings and patients participate

Introducing Underserved Population Network (UP)

Launch of the Home Health Cardiovascular Data Registry

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HHQI Phase 4 Focus

Cardiovascular Health

Reducing HospitalizationsReducing Hospitalizations

Chronic Diseases, Falls Prevention & Wound Care

Reducing Disparitiesg p

11 SOW QIN-QIO Map

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Home Health Now Part of QIN-QIO Core Work

Home Health is returning to QIO Core Work after 6 year absence after 6 year absence 

QINs‐QIOs will be working with limited number of HHAs in each state on the following:– HHQI evidence‐based practices  

– Cardiovascular health 

– Quality improvement

• Contact your QIN‐QIO immediately

Million Hearts® Initiative

Launched 2011

Co‐Leaders: CDC & CMSCo‐Leaders: CDC & CMS

All settings

Goal: Prevent 1 million heart attacks and strokes by 2017

Million Hearts®

The Million Hearts® word and logo marks, and the Be One in a Million Hearts® slogan and logo marks and associated trade dress are owned by the U.S. Department of Health and Human Services (HHS). Use of these marks does not imply endorsement 

by HHS. Use of the Marks also does not necessarily imply that the materials have been reviewed or approved by HHS.

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What are the ABCS?

Cardiovascular Disease (CVD) - National

Heart Disease is #1 Heart Disease is #1 f d hf d h

Stroke is #4 cause of Stroke is #4 cause of d hd hcause of deathcause of death deathdeath

1 out of 3 deaths 1 out of 3 deaths related to CVDrelated to CVD

Greatest contributor Greatest contributor to racial disparity in to racial disparity in 

George, Tong, Sonnernfeld, & Hong, 2012; Roger VL, et al. Circulation. 2012;125:e2‐e220. & Heidenriech PA, et al. Circulation. 2011;123:933–4

related to CVDrelated to CVDlife expectancylife expectancy

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So Why Does it Matter?

HHQI CV Health Improvement Initiative

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HHQI Cardiovascular Resources

HHQI National Campaign Website

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HHQI National Campaign Website

BPIPs on HHQI Website

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Aspirin

Aspirin for Prevention

Risk Factors: Heart AttackAgeDi b t

Risk Factors: StrokeAgeHi h bl dDiabetes

Elevated total cholesterolElevated high‐density lipoprotein cholesterol levelsHigh Blood PressureTobacco useDiet, obesity, physical inactivityAlcohol use

High blood pressureDiabetesTobacco or alcohol use Hx of cardiovascular diseaseOverweight/obesity, physical inactivityHx of TIAs or Sickle Cell disease

AHRQ, 2002; CDC, 2009, Heart Disease Risk Factors; CDC, 2010, Risk Factors for Stroke; Right Diagnosis from healthgrades, 2013; and Erhardt,et al., 2013

Heredity HeredityGender & race

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Clinician Fact Sheet

How Do We Add ASA Education to Our Home Health Visits?

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Multimedia Tools

3‐minute video by Mayo Clinic AHA’s series of animated pictures with text on 15 different cardiac topics

ASA Campaign Example

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Blood Pressure

Risk of preventable death from heart disease

SOURCE:SOURCE: National Vital Statistics System, US Census Bureau, 2008‐2010.

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Hypertension ClassificationsHypertension Classification: Stages and Management (JNC 7 Express, 2003, p. 3)

BP Classification *Systolic BP, mm Hg

*Diastolic BP, mm Hg

Lifestyle Modification

Initial Drug Therapy: Without Compelling indications**

Initial Drug Therapy: With Compelling Indications

Normal <120 and <80 Encourage No antihypertensive drug indicated

Drug(s) for compelling indications

Prehypertension 120‐139 or 80‐89 Yes No antihypertensive drug indicated

Drug(s) for compelling indications

Stage 1 hypertension 140‐159 or 90‐99 Yes Thiazide‐type diuretics for most; may consider ACEI; ARB, BB, CCB, or combination

Drug(s) for compelling indications;Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed

Stage 2 hypertension >160 or >100 Yes 2‐drug combination for most*** (usually thiazide‐type diuretic 

Drug(s) for compelling indications;Other antihypertensive 

and ACEI or ARB or BB or CCB)

drugs (diuretics, ACEI, ARB, BB, CCB) as needed

ASH/ISH guidelines (Weber, et al, 2013), AHRQ, 2002; CDC, 2009, Heart Disease Risk Factors; CDC, 2010, Risk Factors for Stroke; Right Diagnosis from healthgrades, 2013; and Erhardt,et al., 2013

Recommended Lifestyle Modifications for Hypertension ManagementLifestyle Modifications  Systolic BP reduction 

range (approximated)Links to Patient Tools

Weight Reduction 5‐20 mm Hg / 10 kg of weight loss

Aim for a Healthy Weight : Keep An Eye on Portion SizeAim for a Healthy Weight: Patient Booklet

Adopt DASH eating plan 8‐14 mm Hg At‐a‐glance: Lowering your Blood Pressure with DASH

Recommended Lifestyle Modifications for Hypertension

with DASHYour Guide to Lowering Your Blood Pressure with DASH

Dietary sodium reduction 2‐8 mm Hg Where’s the Sodium?Sodium Tip Sheet

Physical Activity 4‐9 mm Hg Your Guide to Physical Activity and Your Heart

Moderation of alcohol 2‐4 mm Hg Fact Sheet—Alcohol Use and Health

Alcohol and Heart Disease

STOP SMOKING for overall cardiovascular risk reduction 

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Will your efforts make a difference?

If every elevated systolic blood pressure was reduced by 5 mm Hg, results would include:

14% overall reduction in mortality due to stroke

9% reduction in mortality due to CHD

7% decrease in all‐cause mortality  

reduced by 5 mm Hg, results would include:

JNC 7 Complete, 2004

Blood Pressure Assessment

Accurate Blood Pressure Monitoring Pressure Monitoring– Steps for accuracy

– Video and article from New England Journal of Medicine

Blood Pressure Accuracy & Accurately Assessing– Blood Pressure Accuracy & Accurately Assessing Orthostatic Hypotension

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Right Equipment is Essential

Compliance Fairs or Annual Field Evaluations

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Comprehensive Post-Tests

Blood Pressure Self-Monitoring

Ambulatory Blood Pressure M it iMonitoring– Regular measurement of BPoutside of clinical setting

– Example – home monitors

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BP Cuff Wish Card

Bulletin Boards

Sample design

Word document with sample text

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Cholesterol

Cholesterol Data

aat least 1 of 3t least 1 of 3

4545%%Adults with diagnosed        or undiagnosed: 4545%%

2 of 32 of 3

1313%%

gHypertension

Hypercholesterolemia

Diabetes

1313%%3 of 3 3 of 3 

33%%

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Patient Engagement

Cholesterol Education Videos

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Game Time

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Smoking Cessation

Smoking

Most important preventable cause of premature death in US

Increases risk of developing many chronic disorders –including atherosclerosis, leading to MI & stroke

p

AHA, 2012

Controlling/ reversing atherosclerosis is an important to preventing future heart attacks and strokes

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Ch D id if iSet a QUIT

Smoking Cessation: AHA 5-step Process

Choose a method for 

quitting

St ki

Decide if using medication might help

QDate& sign a no‐smoking 

contract

M k l f Stop smoking on your QUIT Day

AHA, 2011

Make a plan for  your QUIT Day

“How am I suppose to do smoking cessation and everything else?”

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Smoking Smoking JoeJoe

The Story of Smoking Joe

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Bulletin Boards

Sample design

Word document with sample textWord document with sample text

Health & Wellness

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Health Screenings

Employees Smoking Cessation

Do you or insurance plan offer convenient cessation programs?cessation programs?

How about your HHCAHPS? Do you ever receive complaints or request for non‐smokers?

Is your organization considering a no‐smoking policy at the office?

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Agency Wellness

BMI, Cholesterol, & BP monitoring

Weight Watchers at Work

Activity logs

Lunchtime walks

Zumba after work

Running programs

“Bi L ”

Healthy snacks 

Food tips 

Recipe exchanges

Office salad bar

“Biggest Loser” Competitions

OLA ALA

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Employee Support

Insurance Premiums

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Staff Games/Group Discussions

Jeopardy type games with facts on ABCSCompetency Fairsp y– Include activities to guess facts with prizes

• How many mm Hg reduction will reduce a person’s mortality due to stroke by 14%?

Contests– Individuals or teams

• Name the risk factors for MI &/or Stroke

Scenarios and discuss intervention strategies– Including non‐adherent patient and physician scenarios

Bulletin boards, quizzes, and podcast

Multidisciplinary Approach for Blood Pressure Control

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Leadership

• State agency expectation of who and when are to assess BP• Establish standardized protocols related to BPs and other ABCSPolicies & p• Revise parameter standards (e.g., < 150/90 or less)• Modify EHRs for easy access to trending vital signs• Use standardized communication systems and tools (e.g., SBAR)

Policies & Procedures

• Ensure all staff have access to accurately working equipment• Accommodate for hearing impairments• State agency expectations for routine cleaning, inspections, and testing 

Equipment

Leadership

• Create a sense of urgency for integrating preventable CV healthCardiovascular 

• Select appropriate resources• Use games, skits, etc. at staff meetings to convey importance

Prevention Culture

• Assign staff member to abstract and enter HHCDR datad hl d h l h ffC di l • Review HHQI data monthly and share results with staff

• Use PDSA cycles to assess and modify CV interventions (start small and build)

Cardiovascular Health Data

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Nursing

• Validate that each nurse has right size equipment• Ensure BPs correctly – sounds simple but not always done• Assess vital sign trending each visit – all disciplines

Accurate Assessment • Assess vital sign trending each visit – all disciplines

• Ask for patient specific parameters or utilize agency standardize protocols

• Use standardized effective communication methods (e.g., SBAR)

Communicating with Physicians & Practitioners

• Teach all lifestyle modifications often through out episode of care• Acknowledge that these modifications will effect most chronic diseases 

Lifestyle Modification Education

Therapy

• Establish home exercise program & provide safety educationPT

Take BPs on all visits

Obtain SN referral

• Provide postural syncope education, especially with bathing

• Teach self‐management of medications to improve adherence 

OT

Obtain SN referral for further assessment and education, if needed

Teach self‐management of 

• Evaluate, treat, and teach on swallowing issues with pills/fluids

• Teach cognitive skills to improve adherence to medications 

SLPg

medications to improve adherence

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Ancillary Staff

• Build community resourcesf d b k l

Social • Create food bank lists• Connect with local faith organizationsWorker

• Educate on cardiac health  including diet• Check BP accuracy and parameters on careHHA • Check BP accuracy and parameters on care plans

• Teach s/s to report

HHA

Home Health Cardiovascular Data Registry

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Home Health Cardiovascular Data Registry (HHCDR)

Aligns with physician quality measures (PQRS)Aligns with physician quality measures (PQRS)

Includes patients with the following:– Hypertension

– Ischemic Vascular Disease

– Dyslipidemia

– Tobacco use

HHQI Phase 4 Focus

Cardiovascular Health

Reducing HospitalizationsReducing Hospitalizations

Chronic Diseases, Falls Prevention & Wound Care

Reducing Disparitiesg p

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Next Steps

1. Register for HHQI & Cardiovascular Health Data Registry– www.HomeHealthQuality.org– Stay tuned for Phase 4 Kick‐Off Event info

2. Connect with your state QIN‐QIO or Network Coordinator– QIN‐QIO – see listing 

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press‐releases/2014‐Press‐releases‐items/2014‐07‐18 htmlreleases/2014 Press releases items/2014 07 18.html

– Network Coordinator listing ‐http://www.homehealthquality.org/About‐Us/Partners/HHQI‐Network.aspx

Next Steps

3. Review the Cardiovascular Health BPIPs– Begin with Aspirin and Blood Pressure Controlg p

– Determine if BPs are being taken accurately and consistently

4. Connect with HHQI through Social Media– Facebook,  LinkedIn, Twittter, MY HHQI Blog, Live Chat

– www.HomeHealthQuality.orgy g

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Questions?

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Thank You!

Contact Information:

Ci d S @ iCindy Sun – csun@wvmi.org

Misty Kevech – mkevech@wvmi.org

Crystal Welch – cwelch@wvmi.org

And of course, we can always be reached at , y

HHQI@wvmi.org

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HHQI

www.HomeHealthQuality.org

This material was prepared by Quality Insights, the Quality Innovation Network‐Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication Number: 11SOW‐WV‐HH‐MMD‐091514