Hypertension Control Change Package

Change ideas

Resources

Implement Standardized Protocol with Fixed-Dose Combo Pill

Fixed-dose combination medication decreases the daily pill burden for patients, which improves medication adherence. Multiple studies have shown that this helps patients achieve blood pressure control more quickly and lowers their cardiovascular disease risk. A simple, standardized algorithm can mean fewer steps to titration, fewer medications, and faster control with fewer visits.

• Kaiser Permanente National Hypertension Treatment Algorithm – National Kaiser Permanente guidelines support the goal of <140/90 for all patients, with consideration of SBP <130 in high risk (10 year CVD risk >10%, CKD, CVD, age 75+). Combination pill treatment works best with newly diagnosed patients, but it also works well for patients on one of the two medications and not in control.
• Efficacy and Safety of Dual Medication Therapy in Treatment of Hypertension – This 2019 study concludes that compared with standard dose monotherapy, initiating treatment with low-to-standard dose dual combination therapy is more efficacious without increasing withdrawals due to adverse events.
• Treatment Intensification Considerations for Elderly Patients – Most elderly patients and frail adults can also benefit from treatment intensification with a few additional considerations.

Utilize Non-Physician Providers for Treatment Intensification with Follow-Up Every Two Weeks Until Blood Pressure is Controlled

Team-based care with titration by a non-physician (pharmacists, physician assistants, nurse practitioners and registered nurses) is considered the most effective method to lower blood pressure for several reasons:

• Physicians are now freed up to care for more complex patients.
• Non-physicians focus on hypertension and hypertension-related issues only during these visits.
• Titration is accomplished using a standard protocol and standing orders with a fixed dose combination medication.
• Follow-up every two weeks creates a sense of urgency and engagement with patients and providers.

For health centers concerned about non-billable visits, consider using a co-visit or shared visit approach where providers check in at the end of the visit.

• Kaiser Permanente Southern California Registered Nurse Hypertension Treatment Algorithm – This standardized treatment algorithm for medication titration allows registered nurses to intensify treatment for patients with uncomplicated hypertension.
• Peer Example: Registered Nurse Standing Orders for Blood Pressure Control – Redwood Community Health Coalition provides this policy and procedure guidance for their member health centers. It includes standing orders for treatment intensification by registered nurses.

Monitor Treatment Intensification with Performance Feedback

Give providers both their specific control rates and their specific treatment intensification rates, if possible. This helps providers see opportunities to be more aggressive with their treatment intensification and overcome therapeutic inertia. Given the higher prevalence of hypertension among Black/African American patients, it’s important to stratify data by race/ethnicity in order to specifically address this disparity.

• Example Provider-Level Feedback on Blood Pressure Control Rates – In this sample report, simple metrics based on reliable data allow providers insight into the blood pressure control rates of their panel.
• Measures of Treatment Intensification (Treatment Intensification Score) – Kaiser Permanente has used several different metrics to calculate and monitor treatment intensification for patients with uncontrolled blood pressure.
• Addressing Treatment Intensification Disparities – These sample reports from Kaiser Permanente help providers and staff monitor their treatment intensification efforts and care for Black/African Americans.
• Example Performance and Outcome Report – This detailed provider report offers an example of how to collect and monitor data about treatment intensification and other therapeutic interventions. Health centers can also look into registries and “morning huddle” reports to see which patients may be good candidates for treatment intensification.
• Clinical Inertia Assessment – If the data to automatically monitor treatment intensification is difficult to obtain, consider using this assessment tool to conduct periodic audits.

Train Medical Staff on How to Deal with Common Side Effects of Medication

Patients should not necessarily stop medication immediately when they experience a side effect. Make sure providers are comfortable with how to manage the common side effects of the treatment algorithm’s highly effective medications. Educational modules could include case studies, indicating which side effects are dose-related and when medications should be discontinued.

• Kaiser Permanente Presentation: Common Side Effects of Algorithm Blood Pressure Medications – A presentation by Dr. Joel Handler, clinical leader of Southern California and National Kaiser Permanente hypertension programs, addresses the common side effects of blood pressure medication and associated strategies.

Consider Treatment Intensification Even with Suboptimal Adherence

Non-adherence is often a reason that providers do not intensify treatment. However, treatment intensification improves outcomes safely regardless of adherence rate because adherence is not binary. Patients usually fall on a continuum of adherence between the two extremes of never taking medication and always taking medication as directed.

• Study: Intensifying Therapy for Hypertension Despite Suboptimal Adherence – In this observational study, treatment intensification was associated with similar blood pressure improvements regardless of the patient’s level of adherence.

Change ideas

Resources

Automatically Schedule a 2 to 4 Week Follow-Up Visit When a Patient Has High Blood Pressure

Patients with elevated blood pressure should have a follow-up visit within two to four weeks. Two weeks is most effective because it creates a sense of urgency and importance for providers and patients. In addition to treatment intensification, these follow-ups provide the opportunity for ongoing patient education and engagement. For efficiency, automatically book a follow-up appointment before the provider sees the patient if blood pressure is elevated.

• Peer Example: Elevated Blood Pressure Workflow– In this example from Golden Valley Health Centers, the workflow for repeat blood pressure checks is diagrammed along with specific questions about medication adherence.
• Kaiser Permanente Blood Pressure Check Visit Policy and Procedure – This document provides detailed workflow guidance to medical assistants, licensed vocational nurses and registered nurses on how to conduct and document blood pressure checks based on the patient’s blood pressure reading.

Track if Follow-Up Appointments Are Being Scheduled and Whether Patients Are Keeping Them

Provide care teams with data on a monthly basis so they can track their performance on scheduling follow-up appointments and access data to reach out to patients who missed their follow-ups.

• Example Blood Pressure Follow-Up Monthly Data Report – This sample report shows that regardless of a patient’s chief complaint or presenting department, blood pressure follow-up data is collected and monitored.

Provide Health Coaching to Encourage Medication Adherence

Medication adherence can be a challenging part of intensifying treatment to achieve blood pressure control.  Motivational interviewing techniques offer a helpful strategy for addressing this hurdle and takes into account each patient’s level of readiness.

• Improving Medication Adherence Among Patients with Hypertension: A Tip Sheet – This tip sheet developed by the CDC’s Million Hearts program offers a method for health coaching to improve hypertension medication adherence.
• Kaiser Permanente Motivational Interviewing for Medication Adherence Workshop/Presentation – The materials from this workshop are aimed at improving medication adherence and learning motivational interviewing techniques. Discover which motivational interviewing strategies best help patients at different levels of readiness see the importance of taking their blood pressure medications.

Educate Patients about Hypertension Control and Heart-Healthy Choices

While medication and treatment intensification are the best evidence-based opportunities for blood pressure control, providing education on nutrition, exercise and smoking cessation can help patients to achieve and sustain blood pressure control. It also helps them develop lifelong healthy habits.

• Case Study: Preventing Heart Attacks and Strokes in Downtown Oakland – In this video case study, Douglas Frey, Family Nurse Practitioner at LifeLong Medical Care, describes how an integrated team approach coupled with the right patient education can make a significant difference in blood pressure control.
• My Life Check Healthy Lifestyle Tool – This interactive online tool from the American Heart Association helps people assess and track their heart health information and gain a better understanding of their risk of heart disease and stroke. Print infographics as handouts for your patients.

Implement a Self-Measured/Home Blood Pressure Monitoring Program

Self-measured blood pressure (SMBP) control monitoring helps patients better self-manage their high blood pressure and allows providers to diagnose and manage hypertension more effectively. It is a key element in hypertension guidelines, and many health centers have used SMBP to help patients achieve blood pressure control.

• Self-Measured Blood Pressure Monitoring: An Implementation Guide for Healthcare Organizations – This implementation guide from the National Association of Community Health Centers is designed to help health care delivery organizations implement SMBP into practice or optimize existing SMBP processes.
• Case Study: Livingston Community Health’s SMBP Program – This case study details components of Livingston’s successful pilot program for self-measured blood pressure control, from the strategic commitment to quality improvement that spawned it, to the health coaching and education program that enhanced it, to the data analytics that support it.