HBP Management and Tools

Gregory A Parkin MDJonathan Anderson

HBP: a top priority in 2017

HEDIS and NCQA

Ways to improve “in control” numbers

New Intermountain data on rapid cycling and pharmacy services.

New tools and reports available to improve HTN population management

CPM review and Icentra care pathways

Tips to get your VRP

And 2 exciting video clips!

Important HBP Questions

“I don’t like the HBP CPM because it just focuses on too many random numbers.”

How do you comply with federal regulations?

How do you focus resources to those at highest risk?

How do you manage all the random numbers?

HEDIS and NCQA

HEDIS- A tool used by health plans to measure performance

NCQA – National Committee of Quality Assurance.

Develops quality standards and performance measures. Frequently uses Hedis measures.

A health plan with just 100,000 members: each quality measure = ~ $17 million in reimbursements from federal or state agencies

20-25 measures ($340 million dollars)

Because of the financial importance our physician reimbursement is now being based on value and goals.

HEDIS HBP Measurement

Based on the most recent clinic BP readingHome Blood pressures do not countMust have the diagnosis of HTNBased upon the BP reading of the treating physician. Must be seen during past 12 months by treating clinician. Goals:

Age 18-59 < 140/90Ages 60-85 < 150/90Ages 60-85 & DM < 140/90

Breakdown of my Uncontrolled HBP (2012)

Controlled / needs 12 m recheck

40%

Physician - No recheck done

19%

BP at Other Specialties

13%

Active Rapid cycling14%

Rapid cycled / Compliance issues

7%

Rapid cycled/ controlled at home

7%

Uncontrolled HTN

2016 - Red section has almost vanished. List has decreased from 204 to 148

With new 15 month rule • list now is 116 patients.• Not seen 15-36 m = 43% of list

In-control now is 80% (Intermountain rules)

HEDIS = ~ 95% in-control

How to manage and improve your “in-control” numbers.

Recheck every high blood pressure after 5 minutes while in the office. 80% go down by over 10 points on recheck

HBP Hearts

Rechecking them in the clinic is far easier than getting patients to return.

Rapid cycling every 2 weeks: a team approach

Schedule a follow up clinic visit in 3 months

Yearly follow up for those in control.

Use care managers and care guides to perform population management

Rapid Cycling

A better way to get controlled.

Rapid Cycling and Clinical Teams

Rapid cycling is referring patients to the care manager or the Integrated Pharmacy Services team for follow up every 2-3 weeks.

It is convenient to the clinician and it gets patients to goal faster.

Do we have any data that this works?

Approach

Pharmacy – Personalized Primary Care Integration

Pharmacy Services Chair: Peggy Tilbury

Intervention participants:

Participated in pharmacy integration pilot from August 2012 to May 2015

Independent chart review by pharmacists to confirm participation

Clinics: Salt Lake Clinic, Bountiful, Memorial, Southridge, Rose Canyon, Sandy, Senior clinic

Control patients• Had a PCP visit during August 2012 to May 2015

• Clinics within Central SL and South SL withoutpharmacy integration available

Propensity matched controls using a 1:4 ratio to ensure similarity in comparison• Patient demographics, chronic diseases, duration of HBP

and DM disease, and practice characteristics (#patients on PCP panel, #providers in clinic, TBC implementation level)

Intermountain Clinical Pharmacy Services

• 3 Clinical Pharmacists

• 93% more likely to achieve BP targets

• 87% more likely to achieve HbA1c and BP targets

• 57% more likely to achieve HbA1c target

My Rapid Cycle Hot Text TemplatePeggy Tilbury – Pharmacy Services. Must be registered

HYPERTENSION MANAGEMENT REQUEST

Blood Pressure is running high.

Goal BP: {|< 130/80 Kidney Disease with Proteinuria/ or Young Diabetic|< 140/90 Uncomplicated HTN|< 150/90 Elderly, age 80 or over|}

Previous Medication Regimen: __

Intervention proposed: __

Referral to Pharmacy Services: {|Yes|No|}

Patient is to recheck the blood pressure at home 5 times. They are to be seated for 3 minutes before the reading is made.

Please call in 2 weeks for their numbers.

Please review with them lifestyle changes such as diet and exercise.

Thank You.

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Rapid CyclingACTION POINTDecide if you will start the process of Rapid Cycling

Meet with care manager on work flow.

• How to contact care manager

o Put contact person ( CM or Pharmacy services) in your drop down message log common list

• Hot text/ Auto text / Dragon template

o Elements: Goal BP / medications / Interventions

Decide on signing up for Pharmacy Services. Forms must be completed.

Jeff Olson, PharmD, BCPSCommunity Pharmacy Clinical Managerjeff.olson@imail.org

Numbers, Numbers, Numbers- What is the HBP report?

HTN Reports –

How to use them.

Jonathan Anderson

What is the HTN report?

How do I access the High Blood Pressure reports?

Where is Intermountain with BP control?

In control: Where is my clinic and where am I?

Can I focus my resources on the higher risk patients?

What is a correction tool and how or when do I use it?

New Filters 2 and 3 consecutive

elevated blood pressures

Filters out highest risk group

May be “higher hanging” fruit but these are the ones that will make a difference

My total list has 116 patients

My 2 consecutive list has 25 patients

Care Management

Population ManagementCare Managers and Care Guides There are 3 populations we would

like to improve

1. Single elevated BP’s ( filter highest to lowest)

2. Controlled BP but overdue for visit

o 15 months to 3 years.

o Easiest group for achieving VRP

3. 2 consecutively high BP’s (highest risk group)

Choose 10 patients from each list. If appropriate schedule an appointment for evaluation.

30 patients per doctor should improve the overall percentage in-control.

Care Process Model - Review

Clinical Programs Icon

Care Process Models and Flashcards can be found on your desktop

Medication suggested cascade• ACE/ARB > amlodipine> diuretic > beta

blocker• Having an order simplifies life and

improves care.

Blood Pressure Goals in CPM• Ages 18- 79 < 140/90• Ages >= 80 < 150/90• Diabetes < 140/90• CHF or MI < 140/90• CKD/ACR > 300 < 130/80

VRP BP goals have been changing. Currently using JNC8.

HBP Hearts

Have MA put a heart on the door if BP check was high. A good reminder to be rechecked by staff or physician.

Catch them while they are still present.

Hearts can be ordered through your care manager.

iCentra Care Pathways

Framework to integrate Intermountain Healthcare's Care Process Model content

Care Pathways are being developed for HBP

The goal is to support guidelines within the CPM

Found in Ambulatory Workflow –try it out.

VRP Tips

VRP BP goals have been changing. Currently using JNC8.

15 month rule. Considered “uncontrolled” if not seen within 15 months – 3 years.

• My list = 43% of my uncontrolled.

• Get them in. “Low lying fruit”

• Lists will be frozen after June 30. Gives clinician 6 months to get patients off list.

• Schedule 1 year appoints for follow up .

• Give only #30 days of refill if not seen in over 1 year. Schedule appointment

The last CLINIC BP is what counts.

• Home BP’s do not count

• Secondary Care: Your BP counts on PCP lists if HTN is diagnosed. Please recheck BP if high!

• Use HTN Hearts on door for recheck. Catch them before they leave

• Population Management: Care guides to scrub lists

• Rapid cycle = Care managers and Pharmacy services

• High BP Specialty Clinic is available. (Resistent HTN) 'RefHeartInst,Cardio‘

Intermountain Pharmacies (all 26 of them) have been trained on quality bp checks.

• They will enter the numbers into HELP2/ Icentra and they will count as a clinic BP

• Send patients to a close pharmacy to get control documented

• Please encourage, support and admonish your pharmacy team in their efforts and documentation

Use Correction Tool if needed.

• Send a message log to care manager if there is an exception to the goal.

o Low diastolics, Dizziness with lower BP, Nursing home resident etc.

Goal: Increase control by 0.5% from start of Jan 1 – end Dec 31

Patients must be diagnosed with HTN to be on the report (i.eHTN entered in problem list or ICD 10 coded.)

Improving HBP Action Points

Recheck every elevated BP after 5 minutes of sittingUse the HBP HeartsRapid cycle every 2 weeks: Care Managers or Pharmacy ServicesSchedule f/u appointments in 3 months or 1 year if controlledCare Managers/ Care Guides to scrub lists• 10 patients for each of the 3 populations. • total 30 patients / clinician

Goal BP’s: JNC8 will be used for the VRP / CPM goals may be a good consideration.

Enjoy the videoThank You