Minnesota Regional Community Health Board Partners With Primary Care
In Minnesota, the Regional Community Health Board serving Carlton, Cook, Lake and St. Louis counties
received Community Transformation Grant funding to collaborate with eight primary care clinics and
implement evidence-based strategies. The goal is to reduce patient’s risk for developing heart disease
and diabetes. Four of the clinics are also implementing evidence-based strategies to address
identification and control of hypertension through the Million Hearts™ Initiative. One of the clinics
participating in the Million Hearts Initiative is located in urban Duluth, Minnesota and the other three
are in rural communities.
The Regional Board Clinical Consultant works with the physicians and clinic staff to implement evidence
based strategies that identify and effectively treat patients with hypertension and promote healthy
lifestyles. The Consultant and other content experts meet with clinic staff monthly by phone or webinar
to share ideas and discuss strategies for improving care. In addition, the Consultant has monthly onsite
visits with clinic quality improvement teams to support effective quality improvement strategies for
hypertension management based on national standards. The Health Board staff works with the
Information Technology staff at each clinic to create data reports that provide timely feedback to
clinicians and staff regarding their rates of hypertension diagnosis and effective treatment. The
Minnesota Department of Health Epidemiologist interprets and trends the data. The Consultant then
meets with the physicians and their teams to implement policies and workflows which support effective
blood pressure identification and treatment.
Partners
Partners include the Minnesota Department of Health, clinic physicians, clinic managers, clinic staff,
pharmacists and local health department staff. Each county has a local health department that
participates in the project by providing resource information for healthy living, healthy eating and
smoking cessation. Local health department staff includes public health nurses, health educators and
nutritionists.
Public Health Nursing Role
The public health nurses in the local health departments connect patients to public health and
community resources
Products Developed
Home blood pressure monitoring program:




All clinics have or will have a written protocol for home blood pressure monitoring to support
hypertension diagnosis and hypertension management.
All clinics received three monitors to lend to patients
One clinic ordered twenty more monitors with grant funding
Other clinics plan to leverage funds to purchase additional monitors
Outcomes
The public health staff is excited about the project and report many positive outcomes. The clinic staff
are enthusiastic about opportunities to collaborate with the public health system and anxious to
increase collaboration. Many of the clinics are in very remote rural areas and are eager for the local
health departments to offer classes and education to their patients.
All the clinics were able to pull and analyze National Quality Forum (NQF18) data on a monthly basis.
The NQF 18 is a CDC national hypertension priority measure. The data allowed the clinics to see progress
in clinic hypertension control. The NQF18 will be included in a new combined Healthy Lifestyle measure,
and will be piloted summer 2014 in three of the participating clinics. This combined measure will
eventually will be a reportable measure for clinics in Minnesota.
The project will be expanding to three additional clinics and will eventually be implemented state wide.
The clinics in the project are part of two health systems. The health systems plan to implement the
hypertension policy and workflow strategies in all system primary care clinics within the next two years.
Contact Info
Louise K. Anderson, RN, PHN, MS
Interim Director
Carlton-Cook-Lake-St. Louis Community Health Board
404 West Superior Street, Suite 220
Duluth, Minnesota 55802
Phone: 218-733-2858
E-Mail: LouiseA@communityhealthboard.org