Hypertension System of Care
Submission Date: December 2012
Entry Type: Case Study
State/Territory Submitted on the Behalf of: Arizona
States/Territories Involved: Arizona
Domain Addressed:Health Systems Strategies
Public Health Issue:This program is in its second iteration (first, completed program was 2010-2012, Yuma County). The second iteration is currently in progress with Maricopa County. For this reason we’ve indicated the project is “In Progress” but highlight results from both the current and completed programs.
Project Objectives:The objectives for the Hypertension System of Care program include (but are not limited to) the following:
1) Development of a Community Health Worker (CHW) program with a clearly defined scope of work and clinician oversight; within a community health clinic setting whose primary patient population consists of one or more of the following priority population groups: African American women, Hispanic males, Asian/Pacific Islanders, and American Indians.
2) Development of a multidisciplinary CHW team at each clinic consisting of at a minimum: 1ea participant from clinic administration, medical professional, designated lead CHW.
3) Identification of medical and behavioral health patients at risk or already diagnosed with hypertension during patient appointment intake.
4) Enrollment of identified patients into an educational program provided by CHWs.
5) Referral of patients in other avenues of treatment/support as they are discovered through the intake process (such as diabetes education, tobacco cessation, etc.)
6) Assessment of the patient’s self efficacy to manage their chronic condition (HTN)
7) Follow-up of the patient by the CHW to increase the successful self-management of hypertension
8) Feedback to the primary care provider by the community health worker regarding the patient’s self-management of their blood pressure.
9) Reassessment of enrolled patients at the appropriate time to measure efficacy in HTN self management adherence.
10)Develop and implement the training of key members of the Community Health Center (CHC) staff, inclusive of Community Health Worker, Community Health Worker Supervisors and other support staff members in the Community Health Worker Model (CHW) and the core competencies, skills and qualities of CHWs.
11) Develop and train the CHC Hypertension Program staff (CHW, supervisor, and key support staff) in the evidenced based Pasos Adelante (Steps Froward) curriculum modified to include critical elements of the Centers for Disease Control, Community Sourcebook: A Training Manual for Preventing Heart Disease and Stroke.
Program Action:This program is targeted at county health departments and the CHCs in their region of responsibility. This ensures we are reaching the population stipulated in the primary objectives: a community health clinic setting whose primary patient population consists of one or more of the following priority population groups with hypertension:
1. African American women
2. Hispanic males
3. Asian/Pacific Islanders
4. American Indians
In order to successfully achieve a systems level implementation of the program, Maricopa County Public Health Department will provide a work plan that indicates how the following will be accomplished:
1. Identify a community health clinic(s) with a priority population that is at an increased risk of mortality from heart disease and stroke in Maricopa County and conduct baseline survey of its existing services relating to the scope of this project;
2. Identify CHWs (via clinic HR personnel) who will attend training offered by the University of Arizona and be assigned the HTN program duties;
3. Identify both internal and external partners who will be involved in this project;
4. Identify a multidisciplinary CHW team at each clinic consisting of a minimum: 1ea participant from clinic administration, medical professional, designated lead CHW;
5. Ensure the development of identification and tracking methods for patients who have been diagnosed with, or are at risk of developing hypertension;
6. In coordination with the AZ HDSP Evaluation staff, implement an evaluation program which will measure at a minimum the following:
6.1. Patient self-efficacy in the area of treatment adherence for hypertension after enrollment in the HTN system of care.
6.2. Integration of CHW’s into the clinic(s) medical and behavioral health treatment system.
7. Ensure the development of a referral system between the primary care providers in both medical care and behavioral health care to move the patient into the CHW/HTN educational/navigation program;
8. Deliver the educational program to the patient(s) who have been referred to the program;
9. Partner with the Arizona HDSP and the University of Arizona to ensure that the activities are being done are successful, delineate a clear scope of work for the CHW, and to ensure program fidelity to the CHW training;
10. Ensure the primary care providers (medical and behavioral health) attend an initial training on the JNC-7 guidelines to prevent, diagnose, and treat hypertension;
11 Ensure that the community health workers/promotoras attend in-service trainings on additional material relating to improving their role as CHW/HTN patient navigators;
12. Develop and implement policies that integrate the community health work
This program is designed to operate with two key stakeholders working in parallel. The program provides a grant to a primary stakeholder responsible for the implementation of the system itself, and the University of Arizona responsible for the training of the CHW/promotora who are working in or will be ‘inserted” into the CHC system.
Partners to date:
Yuma County Health Department
Sunset Community Health Center
Regional Centers for Border Health
University of Arizona College of Public Health and Prevention Research Center
Maricopa County Public Health Department
Wesley Community Health Center
Data/Other Information Collected:The data measures for this project are:
1. Biometric patient data: Blood pressure readings at the time of patient visits
2. System integration data scaling the level of fusion between the clinic system and the new CHW staff
3. Patient self-efficacy before and after the education/navigating program. The Health Clinics themselves have voluntarily collected other measures such as cost control and missed appointment improvements – to name a few.
Impact/Accomplishments:The first iteration of this program ( 2010-2012 with Yuma County) is completed. The second is currently in progress with Maricopa County.
Yuma County program contractors reported (project end June 2012):
- Weight and Blood Pressure:
66% of completers lost weight
18% gained weight
57% Decreased their systolic blood pressure
48% Decreased their diastolic blood pressure
16% stayed the same
27% Increased their systolic blood pressure
35% Increased their diastolic blood pressure
16% stayed the same 17% stayed the same
Quarterly reports reported monitoring of self-management support system and service delivery for each clinic, based on three questions using a scale of 1 to 10, 10 being the highest level of performance. RCFBH reported a rating of 9 in the incorporation of Promotoras into the healthcare team and a rating of 8 in Promotoras providing feedback to PCP’s concerning the identified HTN patient steadily throughout the duration of this program. A significant improvement was reported on the Promotoras conducting follow-up activities with HTN patients to ensure fidelity with self-management training which started with a rating of 6 and increase to a rating of 9 in last quarterly report.
Maricopa County (currently underway) is producing similar numbers in system integration although we will wait for the end of the program to report hard data (to make sure this lasted through the “honeymoon phase” of a new program implementation).
Most rewarding however, are the results from an independent project measuring all Arizona Federally qualified CHC’s ability to comply with Phase 1 of the Meaningful Use requirement:
For the measure NQF 0013 Hypertension: Blood Pressure Measurement. Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension and have been seen for at least 2 office visits, with blood pressure (BP) recorded — the Wesley Community Health Center of Maricopa County (target center for the current program) produced an assessment of 100% compliance with this measure.
Challenges/Lessons Learned:The primary challenge for this project has not been in the implementation of the program (the clinics support it completely, the training program and contractor -U of AZ- is well respected). The primary challenge has been developing better tools to measure the system integration portion of the grant. At its core, these projects are about changing the healthcare system, incorporating the CHW/Promotora model to assist in the navigation, education and coordination of care for the hypertension patient. The biometric measures are the easier part to get at. Finding effective means to measure the qualitative portions of the grant have been an ever-developing progress.
Next Steps:We are still analyzing the results from the completed Yuma County program and closely watching the newly implemented Maricopa County program These programs are different as the Yuma project involved increased HTN training for an already seasoned promotora system. The Maricopa County project was designed specifically to place the HTN/Promotora system into a clinic which had not used this system before. Also, the Maricopa project required the same intake screening and inclusion of its behavioral health patients as it does its medical patients. Because of this, the next steps involve compiling the current process evaluation tools, but the creation of a contrast/compare methodology of the two projects to ensure we are keeping flexible and not attempting to create a “one size fits all” HTN/CHW program.
Program Areas:Heart Disease and Stroke
State Contact Information:
AZ
David W. Heath, MBA
Arizona Department of Health Services
602-364-0140 phone 602-540-6921 mobile
David.Heath@azdhs.gov