Key Changes
Teams will test and implement changes that address the various components of the Planned Care
Model. Table 1 lists the changes for hypertension clinical management
Table 1: Key Changes to Test for Hypertension Clinical Management
Recommended
Standards of Care
Coordinate ‘planned’
care visits
Implement
interventions to
improve the
detection, evaluation
and treatment of
hypertension
Integrate self-
Key Changes
DSD: Delivery system Design
DS: Decision Support
CIS: Clinical Information Systems
SMS: Self -Management Support
CRP: Community Resources and Policies
• Schedule regular planned care visits for patients with hypertension at
least every 6 months and more frequently if BP not at target (DSD,
DS)
•
Routinely review the registry and identify patients in need of followup visits (DSD, CIS)
•
Develop, distribute, and integrate evidence-based guidelines
throughout the health system (DS)
•
Provide staff and provider education on evidence-based guidelines,
BP measurement technique, availability of patient education
resources, etc. (DSD)
•
Implement a system for blood pressure documentation and tracking
protocols (DS, DSD)
•
Implement a system for BMI and Waist Circumference
documentation and tracking protocols (DS, DSD, CIS)
•
Discuss importance of lifestyle choices and anti-hypertensive
medications with patient, including adherence in taking medications,
sodium reduction, tobacco- cessation and weight loss as appropriate
to each patient (SMS)
•
Strengthen method for monitoring adherence to prescriptions
(DSD, SMS, DS)
•
Connect patients with physical activity and weight loss programs in
the community (CRP, SMS)
•
Enhance cross-cultural communication between patient/families and
clinic staff (SMS, DSD)
•
Develop system for prioritizing patient medications when cost and
number of medications are barriers to patient compliance (DSD,
SMS)
•
Empower office staff to follow-up with patients to make follow-up
visits and to review self-mgt goals as appropriate (DSD, SMS, CIS)
•
Schedule a documented encounter at least annually to work
management into the
patient’s care plan
Improve
interdisciplinary
management of
patient’s care
Implementation of
population-based
approach for all
patients with
hypertension
collaboratively with patients in their identification of selfmanagement goals (SMS, DSD)
•
Integrate evaluation of a patient’s readiness to change into the selfmanagement program (SMS, DSD)
•
Implement the use of BP cards for patient self monitoring (SMS,
DSD)
•
Develop a comprehensive program for supporting self-management
(SMS, DSD)
•
Offer regular follow-up support and educational materials (SMS,
DSD)
•
Determine the patient’s ability to purchase prescriptions (SMS,
DSD)
•
Offer home BP monitoring for appropriate patients (SMS, DSD,
DS)
•
Establish protocol assuring appropriate follow-up care (DSD, CIS)
•
Establish or refer to local support group for patients and families
(CRP, SMS)
•
Offer culturally/literacy appropriate education and self-management
materials (SMS, CRP)
•
Continue staff skill building around incorporating self-management
into practice (SMS, DSD)
•
Develop and enhance systems/mechanisms to facilitate
communication between PCP, practice medical/office staff,
specialist, and hospital (DS, DSD)
•
Improve communication between outpatient and inpatient care
providers (DS, DSD)
•
Improve communication with multidisciplinary team and define
roles and responsibilities of practice staff to ensure accountability
and completion of tasks (DSD)
•
Identify contributors to patient’s well-being (e.g., physicians,
community, and care givers) (DSD, CRP, SMS)
•
Foster community links that offer services such as tobacco cessation
classes, exercise programs, cardiac rehabilitation, nutrition
counseling etc. (CRP, SMS)
•
Implement a system of planned and/or group visits (DSD, SMS,
•
Utilize available resources for case management (DSD)
•
Actively use disease management techniques to manage care (DSD,
DS)
MEASURES
Table 2: Required Measures for Hypertension Clinical Track
Patients = Patients in pilot population
Denominator = Number of patients in the pilot population, unless noted otherwise.
Measure
BP to goal:
Statistic *
Numerator: Number of patients with the most
recent (within the past 12 months) BP < 140/90
mmHg (without DM or CKD)** or <130/80
mmHg (with DM or CKD)**
Type of Measure
Outcome
Documentation of selfmanagement goal
Numerator: Number of patients with
documentation of a self-management goal in the
past 12 months
Process
Tobacco-cessation
counseling
Numerator: Number of patients offered tobaccocessation counseling in the past 12 months
Process
< 140/90 mmHg
<130/80 mmHg for
patients with DM or
CKD
Denominator: Number of patients in the pilot
population who use tobacco
Sodium-restriction
counseling
Numerator: Number of patients provided sodium
restriction counseling in the past 12 months
Process
Screening for
overweight and obesity
Numerator: Number of patients with a documented
BMI or Waist Circumference measurement in the
past 12 months
Process
Appropriate
Antihypertensive
medication
Numerator: Number of patients with CKD or DM
prescribed at least one of the following in the past
12 months - ACE, ARB or DRI.
Process
Denominator: Number of patients with CKD or
DM.
Antihypertensive
medication
Numerator: Number of patients prescribed
antihypertensive medication in the past 12
months.
* Numerator divided by denominator, then multiplied by 100, equals the percent of patients meeting the
measure requirements.
** DM and CKD defined using billing codes, see page XX
Table 3: Optional Measures for Hypertension Clinical Management
Patients = Patients in pilot population
Denominator = Number of patients in the pilot population, unless noted otherwise.
Measure
BP < 160/100
mm/Hg
Statistic*
Type of Measure
Numerator: Number of patients with the most recent Outcome
(in the past 12 months) BP of < 160/100 mm Hg
Weight reduction
counseling
Numerator: Number of patients offered weight
reduction counseling or referral in the past 12
months
Process
Denominator: Number of patients with a
measurement showing overweight or obesity (via
BMI or waist circumference)+
Home BP monitoring
Numerator: Number of patients using home BP
monitors in the last 12 months
Process
Physical activity
assessment
Numerator: Number of patients evaluated for level
of physical activity in the past 12 months.
Process
Screening for renal
disease
Numerator: Number of patients with a calculated
Glomerular Filtration Rate (GFR)*****
documented in the last 12 months
Process
*Numerator divided by denominator, then multiplied by 100, equals the percent of patients meeting the
measure requirements.
***** GFR calculated via MDRD2 formula: GFR (mL/min/1.73 m2) = 186 x (Scr)-1.154 x (Age)-0.203 x (0.742
if female) x (1.210 if African-American) (conventional units)
OR
For creatinine methods recalibrated to be traceable to IDMS: GFR (mL/min/1.73 m2) = 175 x (Scr)-1.154 x
(Age)-0.203 x (0.742 if female) x (1.210 if African-American) (conventional units) – used in some labs
(the -1.154 and -.203 are expon. not minus)
Link to GFR web calculator: http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm