PHASE Onboarding Playbook: Care Team

What Care Team Members Need to KNOW

• PHASE is a population health management program developed by Kaiser Permanente that aims to reduce heart attacks and strokes for patients at elevated risk with medication and lifestyle changes.
  Learn More: Participant’s Guide to PHASE
• There is very strong evidence that the PHASE approach works to significantly reduce heart attacks and strokes.
  Learn More: PHASE Clinical Evidence Summary
• Participating in PHASE provides opportunities to receive training, clinical expertise, peer sharing, coaching, customized support and access to online resources.
  Learn More: Participant’s Guide to PHASE
• PHASE involves tracking and continuous improvement of blood pressure control and several other markers (diabetes management, screening & follow-up for tobacco, BMI, depression), for reducing heart attacks and stroke. The outcomes tracked are HEDIS (Healthcare Effectiveness Data and Information Set) standardized performance measures.
  Learn More: PHASE Reporting Template
• PHASE implementation requires capability building in 5 key domains that are important for population health management (engaged leadership, team based care, data driven decision making, panel management, quality and process improvement).
  Learn More: Building Blocks Summary
• The PHASE model and process of implementation is applicable to many performance improvement targets beyond hypertension and diabetes.
  Learn More: HRSA Guide to Improving Care Processes and Outcomes
• PHASE-supported quality improvement is a win/win for patients and the care team. Care processes become more efficient and effective, leading to better patient outcomes and better staff satisfaction.
• BP must be carefully measured according to established protocols to accurately diagnose and manage hypertension.
  Learn More: Measure Up Pressure Down Proper BP Measurement Guidelines, TargetBP: Measuring Blood Pressure
• There is a comprehensive body of evidence to guide hypertension management.
  Learn More: PHASE Support Resource Hub – Hypertension Guidelines
• Successful PHASE implementation and targeted improvements hinge on a dedicated cross-functional team supported by a Clinical Champion.
  Learn More: Participant’s Guide to PHASE

What Care Team Members Need to DO

• Full Care Team: Examine current care processes to identify opportunities for improvement. Help design and implement effective work and information flows. Participate in annual review/completion of PHASE Clinic Assessment to support ongoing practice transformation and care team enhancements. Learn More: Building Blocks Summary, PHASE Clinical Evidence Summary

• Providers: Participate in developing and practicing effective, hypertension guideline implementation and workflows. Deliver evidence-based, patient-focused care supported by practice protocols and clinical decision support (CDS) including huddle reports, order sets, and care gap reports from registries.
• MAs: Learn and apply appropriate techniques for collecting key data, including proper BP measurement. Gather data and provide patient support per protocol (during huddles, patient visit intake, follow-up). Support other roles such as health coaches, nutritionists, diabetes educators, CHWs.
• RNs: Lead efforts to provide health coaching, patient education and manage uncomplicated HTN under standardized procedures or through co-visits with MDs.
• Pharmacist: Support medication management and adherence for patients needing additional assistance.  Support/train RNs on medication titration under standing orders/protocols.
• Staff with Population Management Responsibilities: Use practice protocols to search registries to find patients who have not yet reached targeted outcomes and do corresponding outreach.

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