Appendix A - Program & Service Details (complete a new sheet for each program/service)
Program/Service Name:
Hypertension screening and monitoring
New/Existing: ☐ New
X Existing
Type: X Chronic Disease Management
Clinical Practice Guidelines finalized for Program/Service?
☐ Health Promotion
☐ Seniors Care
☐ Mental Health
Provider
RPN
☐ No
Priority Addressed (choose the one most appropriate):
Prevention
☐ Acute/Episodic Care
Planned Staff Involvement (FTE):
X Yes
FTE
0.5
☐ Diabetes
☐ Lung Health
☐ Obesity/Nutrition
X Heart Health
☐ Smoking/Addictions
☐ Other -
Collaboration with other organizations for program/service:
Referrals into the program by physicians at the Marathon Family Health Team and
the Diabetes Clinicians at Marathon Diabetes Clinic.
High Level Description
& Goals
(2014/15)
1) Target
Number of
Patients,
and
2) Target
Population
(2014/15)
1) # of
Patients
Served
2) Patient
Encounters
**
(2013/14)
Activities
To provide blood
pressure assessments for
early detection of
hypertension (screening)
and on-going monitoring
of BP for patients with
existing hypertension, 1)
and to provide lifestyle
intervention information
to assist with the
management and
prevention of
hypertension.
1) Screening:
55
monitoring: 512
community
clinic: 70
1) Screening:
52
monitoring: 281
community
clinic: 49

2) screening:
patients without
diagnosis of
hypertension
having a high
blood pressure
reading at an
encounter with a
health care
provider
monitoring:

Performance Measures
o Corresponding Targets
 Actual Measure
(2013/14)

Performance Measures
o Corresponding Targets
(2014/15)
Planned Quality
Improvements
(2014/15)

% clients seen by RPN provided with
written material compliments of the
Canadian Hypertension Program
o 60%
 Actual 1

% clients seen by RPN provided with
written material compliments of the
Canadian Hypertension Program
o 60%


% patients with hypertension seen by
RPN with lifestyle goals tracked in
hypertension flow sheet
o 60%

% patients with hypertension with BP
measure in past 12 months
o 95%

% patients with hypertension with last
BP in past 12 months ≤ 140/90
o 60%
(2014/15)

2) Combined:
1258

Recruit and train new RPN
to replace RPN retiring
March 2014.
Continue to take BP
measurements and provide
lifestyle education and
counselling to patients
referred to the program for
screening and monitoring
Provide reqs for labwork
and ECG to clients who fit
the hypertensive criteria
upon completion of blood
pressure screening so labs
and ECG are complete
prior to following up with
the physician.

% patients with hypertension with BP
measure in past 12 months
o 90%
 89%

% patients with hypertension with last
BP in past 12 months ≤ 140/90
o 60%
 44%

Improve tracking of lifestyle
goals and outcome measures
in EMR through use of the
hypertension flow sheet
Establish protocol for only
valid BP measures to be
entered into the EMR
High Level Description
& Goals
(2014/15)
1) Target
Number of
Patients,
and
2) Target
Population
(2014/15)
patients with
existing
hypertension
community
clinic: general
population 18 and
older
1) # of
Patients
Served
2) Patient
Encounters
**
(2013/14)

Activities
(2014/15)



Performance Measures
o Corresponding Targets
 Actual Measure
(2013/14)

Performance Measures
o Corresponding Targets
(2014/15)
Planned Quality
Improvements
(2014/15)
RPN to set a time for
physician follow up
Hold one community BP
clinic with referral to
MFHT for follow up
screening, monitoring or
physician visit as required
RPN to review the Canadian
Hypertension guidelines in
order to be current on new
recommendations.
Stories and Highlights (2013/14)
 Improved efficiency of first appointment with physician for patients with screening outcome of high BP providing patient with requisitions for labs and ECG at last screening appointment.
 Improved communication of screening outcome to physicians through use of screening outcome template
 Revised templates for recording BP measurements
 Created table and graphs for quarterly tracking of outcomes
 Two Tru bp machines purchased
*For new programs/services, do not complete the shaded cells
**Patient encounters may include but are not limited to in-person appointments, telephone contacts, OTN and home visits. Group sessions should count each participant in each session as a patient encounter.
Programs share the following characteristics: a) specific patient group, b) meaningful, measurable objectives/indicators, and c) outcome measures/indicators that allow the FHT to determine whether the objectives have been achieved