Healthy Hearts for Marylanders
Submission Date: December 2014
Entry Type: Case Study
State/Territory Submitted on the Behalf of: Maryland
States/Territories Involved: Maryland
Domain Addressed:Epidemiology and Surveillance, Health Systems Strategies
Public Health Issue:Heart disease and stroke are the first and fourth leading causes of death in the United States, accounting for 1 of every 4 deaths. Healthy Hearts for Marylanders is a statewide effort to achieve improvements in quality of care and health outcomesâparticularly outcomes related to the ABCS of heart healthâamong patients diagnosed with diabetes.
Project Objectives:The project sought to improve clinical care quality related to ABCs for patients with diabetes in Federally Qualified Health Centers.The target population included medically underserved and uninsured residents. The initiative targeted individuals with a diagnosis of type 2 diabetes who were between 18-75 years of age, not pregnant, and had at least one documented blood pressure reading, HbA1c measurement, and LDL cholesterol measurement at a participating FQHC.
Program Action:The project targeted primary care practitioners in Federally Qualified Health Centers (FQHCs) in 2009. The Maryland Department of Health and Mental Hygiene Center for Chronic Disease Prevention and Control (CCDPC) and a partner, the Mid-Atlantic Association of Community Health Centers (MACHC), developed a system for providing technical assistance on primary care quality improvement that is modeled on the HRSA Health Disparities Collaborative. Community health centers are engaged in rapid-cycle quality improvement with the aims of improved hemoglobin A1C, blood pressure, and cholesterol control and smoking cessation for patients. Clinical quality improvement steps include data analysis & surveillance; health care systems interventions to empower health care teams including audit & feedback, reminder systems, academic detailing & improved care coordination; community interventions to empower patients through self-management education; and policy interventions such as including comprehensive, integrated strategies in MD plan for diabetes, HD&S, & chronic care management.
In 2012, the pilot program was expanded to include appropriate aspirin use for those at risk, immunizations, and breast and cervical cancer screenings. Following the pilot project, Health Hearts was used as a clinical quality improvement framework and expanded to over 34 FQHC sites across the state, reaching over 175,000 Marylanders. In 2013, this framework was applied to Million Hearts efforts in private practices and health systems in four target jurisdictions- Baltimore City, St. Mary’s, Washington, and Cecil counties.
Partners include:Mid-Atlantic Association of Community Health Centers
Total Health Care Inc.
View Maryland’s Million Hearts Implementation Guide here.
Data/Other Information Collected:CCDPC established four Key Performance Indicators to monitor health outcomes through Healthy Hearts:
⢠Increase the percentage of HbA1c Control (<7%) to at least 65% or 10% above baseline.
⢠Increase the percentage of BP control (< 130/80) to at least 65% or 10% above baseline.
⢠Increase the percentage LDL Control (< 100 mg/dl) to at least 65% or 10% above baseline.
⢠Increase the percentage of non-smokers to at least 65% or 10% above baseline.
Impact/Accomplishments:n 2009, Healthy Hearts for Marylanders was implemented in four FQHC locations (two sites from two FQHCs) in Baltimore City. With technical assistance from CCDPC and MACHC, systems changes were made in participating clinics to improve hypertension management. These changes included adding reminder functions to electronic health record (EHR) systems to trigger providers to look at blood pressure, providing manual blood pressure cuffs in all exam rooms to allow physicians to easily recheck blood pressures, initiating a medication management program in partnership with a pharmacist who worked with diabetic and hypertensive patients to review medications and address barriers to adherence, changing where blood pressure readings are physically recorded in the EHR, and using EHR reports to monitor progress made towards benchmarks.
The program has resulted in an increase in blood pressure control (<130/80) from 17% at baseline (2009) to 44% within the participating sites. The FQHC sites consistently exceeded Maryland and National 2011 HEDIS benchmarks for the KPIs; exceeded 2011 Maryland UDS benchmarks for HbA1c, BMI, blood pressure management, and smoking status; and made âremarkableâ progress in assisting patients to stop smoking.
Challenges/Lessons Learned:When Healthy Hearts implementation began in 2009, some of the participating FQHCs were just establishing EHR systems and therefore accessing data from these systems was an initial barrier. For example, THCâs system allowed only one-way communication with its practice management system which created challenges, particularly around extracting data based on ICD9 diagnosis codes.
Even when an EHR system was in place, many electronic charts lacked key pieces of data that resulted in validity issues. In fact, a major finding in the baseline analysis revealed 51% of reviewed medical records were missing documented values for several key clinical measures including at least one documented blood pressure reading, HbA1c value, and LDL cholesterol level.
Another challenge involved lack of training/expertise among site staff in extracting the appropriate data for required quarterly reports to MACHC. MACHC provided continuous quality improvement to staff to ensure optimal data extraction, interpretation, and use for clinical decision making and quality improvement.
Next Steps:Lessons learned from Healthy Hearts for Marylanders informed the statewide Maryland Coordinated Chronic Disease Plan, which serves as a roadmap for public health leaders and partners to work collaboratively across chronic disease conditions and risk factors in order to effectively meet population health needs while also reducing gaps in health status across population subgroups experiencing the greatest burden of chronic disease.
Program Areas:Heart Disease and Stroke
State Contact Information:
MD
Adelline Ntatin, MPH, MBIM, MA, Program Administrator
Maryland Department of Health & Mental Hygiene
410-767-2623
adelline.ntatin@maryland.gov