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J Clin Hypertens (Greenwich). 2012;14:178–183. ©2012 Wiley Periodicals, Inc.
Over the past two years, the business community of Monroe County, which includes Rochester, New York, has been engaging in a collaborative to improve outcomes for people with high blood pressure. As the employers examined the costs of care in the community, they recognized two important factors. First, the costs of care for the uninsured, the underinsured, and the Medicare population influence the business community's cost of care. Second, trying to redesign care just for their employees alone was not effective. This project is unique in that the stimulus and funding for community-wide action comes from the business community. They saw beyond the often unsuccessful short-term cost reduction programs and joined with a community-focused organization, the Finger Lakes Health Systems Agency, to construct a multi-year, multi-faceted intervention designed to encourage practice redesign and an invigorated community commitment to partnership and accountability. This report describes the process to date and hopefully will stimulate conversations about mechanisms to encourage similar collaboration within other communities.
Nearly one third of Americans (73 million) have high blood pressure (HBP) and the incidence of the disease has not changed significantly in the past 10 years.1–3 HBP is thought to contribute to 1 of every 7 deaths and nearly half of all cardiovascular disease–related deaths in the United States.3 While control of blood pressure (BP) has increased from 27.3% in 1988–1994 to 50.1% in 2007–2008,2 half of the hypertensive population’s BPs remain above recommended targets. Even among patients being treated in medical practices, 30% of patients’ BPs remain ≥140/90 mm Hg.2
The risk to the elderly population is even more dramatic. Patients older than 60 have an increased incidence of the disease and significantly lower rates of control and are at greater risk for the associated morbidity of HBP including stroke, heart attack, heart failure, and the initiation of dialysis.2 At the same time, the cost of these morbidities is significant. For example, the direct and indirect cost of stroke in the United States annually is estimated at $73.7 billion.4 In addition, the prevalence and incidence of renal failure treated by dialysis and transplantation in the United States increased between 1988 and 2004.5 The National Kidney Foundation estimates the yearly cost of hemodialysis per patient at $75,000.
While many have advocated for systematic, population-focused interventions to improve BP control,1,6 a formula for success has remained elusive. Recently, Egan and colleagues reported on a successful program in South Carolina that uses a multifaceted intervention to improve control.7 Their approach builds on the chronic disease model introduced by Wagner and colleagues.8,9 Wagner’s model describes the important interconnected roles all community stakeholders play in successfully addressing the complexity of improving outcomes in chronic diseases. Wagner argues that to be successful, both patients and practitioners need be more actively engaged in the care process. But, he argues, more is needed. In addition to activated patients and practitioners, there needs to be a community effort to organize and provide information and services needed for those activated patients and practitioners. These community services are designed to provide the resources activated patients need to successfully make and sustain the lifestyle changes required to control and, more importantly, prevent HBP.
Engaging the entire community takes leadership and simultaneous interventions strategically initiated to offer human and health care services, health insurance and employee benefits, and accurate and timely data when and where they are needed. There is accumulating evidence that these types of multifaceted interventions can be successful.10,11
During the past 2 years, Monroe County community, which includes Rochester, New York, has been engaging in a collaborative effort to improve outcomes for people with HBP. This report describes the process to date and will hopefully stimulate conversations about mechanisms to encourage collaboration within other communities of similar size. It should be noted that due to its descriptive nature and the early stage of the project, we do not present results or outcomes that can be subjected to quantitative and/or statistical analysis.
Beginning in 2005, the Rochester Business Alliance (RBA) created the RBA Health Care Team (RBAHCT) to address rising health care costs. In 2008, Paul Speranza, Vice Chairman, General Counsel and Secretary for Wegmans Food Markets, Inc, assumed leadership of the team. Wegmans is a privately held food market chain and leading regional employer that has been regularly selected as one of the 10 best employers in the country12 and has been a consistent leader in fostering employee wellness. The RBAHCT includes representatives from Bausch and Lomb, Jasco Tools, Kodak, Paychex, Rochester Institute of Technology, Wegmans, LiDestri Foods, and Xerox. After considerable investigation, and a series of community conversations, the team determined that the most likely method to successfully reduce health care costs was to focus on transforming health care delivery from a pure visit-focused approach to one that also includes population management.
In 2009, recognizing that this transformation required more than simply reforming the payment system, the RBAHCT decided to focus on reducing the cost of and improving the clinical outcomes for patients with HBP as an initial venture into redesigning the care process. HBP was selected because of community feedback; the existence of well-accepted, evidence-based guidelines;13 the availability of cost-effective treatments, and the direct correlation between improved recognition and treatment and decreased morbidity and mortality of the condition. As the employers examined the costs of care in the community, they recognized two additional factors. First, the costs of care for the uninsured, the underinsured, and the Medicare population influenced the business community’s cost of care. Second, trying to redesign care for their employees only would not work. Based on practitioner feedback, an all-payer approach would be needed. To accomplish their goal, the RBAHCT recognized that an employer-centric group would have difficulty in successfully bringing together the multiple stakeholders needed to achieve their goal. A community-based organization with a track record in bringing disparate groups together to a common table would be required, one that had experience in addressing the disparities in care and outcomes that exist in Monroe County.
To address the identified need to create a community-wide focus, in 2009, the RBAHCT turned to the Finger Lakes Health System Agency (FLHSA) to serve as the community convening partner for the project. They selected the FLHSA because of its track record of enlisting multiple stakeholders to address complex access and utilization issues such as planning for regional geriatric services, reducing the incidence of lead poisoning in Monroe County, addressing childhood obesity, and more recently creating and empowering Latino and African American coalitions to provide explicit feedback to community-wide projects.14
Under the leadership of a unique collaboration between the RBA, serving as the Rochester Area Chamber of Commerce, and the FLHSA, a powerful multi-stakeholder coalition including employers, providers, insurers, labor, community organizations, the United Way, and minority consumer coalitions affiliated with FLHSA was organized and empowered to identify and improve the recognition and care of people with HBP in Monroe County. Integrating FLHSA’s ongoing African American and Latino Health Coalitions to identify and address disparities of care brings often overlooked populations to the table as full partners in the planning process.
The Wegman Family Charitable Foundation generously provided initial funding to begin the process of creating an implementation plan, and with the completion of that implementation plan, provided a second infusion of dollars to initiate the implementation. Based on the depth of the community’s response and the enthusiastic support from the health systems and community organizations, in September 2010, the Wegman Family Charitable Foundation contributed to the effort. Part of that support focused on developing a plan to attract sufficient additional funding to maintain the project through 2014, when the project goals are to be met.
Using Wagner’s Chronic Disease Model as a guide, the newly developed implementation team focused on creating multi-stakeholder work groups to focus on the perceived components of a successful transformation program, creating clear measurable goals for the project, increasing community awareness, promoting lifestyle change, especially among those at greatest risk of the untoward consequences of HBP, creating community and employer workplace wellness programs to support and encourage behavior change, redesigning care in primary care offices to create a data-driven approach to caring for the entire population diagnosed with HBP in participating practices, and aligning both consumer and practitioner incentives to improve BP diagnosis and treatment. In the process, disparities in care would be measured and reduced.
Each work group has been active over the past 2 years. Their activities are provided below. The metrics and measures group defined the primary and secondary goals of the project and the specifications for each goal. The measures use the years 2009 and 2010 as the baseline periods. Briefly, the project’s primary measures are:
The rates and numbers of hospital admissions for heart attack, heart failure, and stroke and the initiation of dialysis among adults residing in Monroe County, New York. The collaborative goal is to achieve a 5% incremental annual decrease for 2011 through 2014.
The proportion of adults in Monroe County, New York, with HBP who achieve a BP <140/90 mm Hg based on the most recent office reported BP. The collaborative goal is to reach 85% of patients with a last recorded BP of <140/90 mm Hg by 2014. Based on the registry data sample for the second half of 2010, the baseline has been established as 63%.
The costs of health care per person with HBP per year. This measure is based on aggregated health plan data that are in the process of being collected. Once the cost of care per person per year is determined, a more specific target will be defined.
Secondary measures include:
The number and percentage of adults who know their BP and know whether it is normal, prehypertensive, or high.
The number and percentage of adults with hypertension or prehypertension who have developed a management plan in partnership with a health care provider.
The percentage and rate of adults who get their BP checked regularly.
The percentage and rate of people with HBP under a doctor’s care.
Attitudes that prevent individuals from seeking care or implementing strategies for management of elevated BP.
The number and percentage of practicing general internists and family physicians (and secondary general cardiologists, endocrinologists, and OB/GYNs) actively engaged in the HBP quality- and process-improvement program.
The hospitalization rates for heart attack, heart failure, and stroke among adults residing in Monroe County, New York, will be obtained from the SPARCS database maintained by the New York State Department of Health. The SPARCS database contains patient level detail on patient characteristics, diagnoses, and treatments for every hospital discharge in New York State. The number of people initiated on dialysis is obtained from the IPRO/ESRD Network of New York database. Through an agreement with the two major health plans in the area to aggregate commercial, Medicare Advantage, and Medicaid HMO medical claims, FLHSA will explore the feasibility of developing measures of the costs of care for treatment of HBP and associated morbidities for individuals with HBP.
The project team is responsible for generating a community report detailing ongoing progress towards achieving the two primary goals and the 6 supporting goals. Emphasis is placed on improving results for the primary and secondary goals. The first report will be distributed in the first quarter of 2012. A cost of care per year measure is anticipated once an aggregated health plan database is operational in the second quarter of 2012.
To provide a sense of the activities created community-wide, a brief summary of each work group’s progress is provided. In order to minimize the creation of silos of activities, the work group chairs meet regularly to share progress and identify and resolve barriers to success.
The community awareness workgroup conducted a community-wide survey that oversampled the African American and Latino community because of perceived existing disparities in care. The survey was administered in person to 400 people primarily at bus stops to oversample the minority population and 1580 people through an Internet survey advertised by the project’s member organizations in June 2010. The results of the survey surprised many.
The primary result was that regardless of the age, ethnicity, and sociodemographics of the populations surveyed, >80% understood that (1) HBP is a silent killer, (2) knowing one’s BP is important, (3) lifestyle changes are integral to successful treatment, and (4) medication is available and reduces the consequences of the disease. In addition, respondents voiced a desire to change their lifestyle. The barrier was not awareness, it was being unsuccessful at lifestyle change.
With these results, the Behavior Change Work Group was created. Using the experience of local experts in behavior change and motivational psychology, the behavior change group focused on 4 pillars: building competence, encouraging a sense of autonomy (the power to choose what is needed to change), creating a sense of community relatedness so all can celebrate each other’s successes, and building a common set of values to which all involved subscribe.15 The project’s core values are transparency, honesty, and respect. Each intervention considered by the other work groups is vetted by the Behavior Change Work Group to ensure that principles of behavior change are embedded in the interventions selected and launched.
The Community Engagement Work Group and the Healthy Worksite Action Team are charged with designing and implementing interventions to identify those with undiagnosed HBP, and create programs that encourage competence, autonomy, and relatedness in the targeted population by focusing on the communities shown to be at most risk: the elderly, African Americans, Latinos, and the socioeconomically disadvantaged. In addition, with the strong support of the business community, workplace wellness has been incorporated into the community engagement work plan. To accomplish these goals, the work groups have elected to focus on a series of demonstration projects.
The demonstration projects are underway in 3 worksites of varied demographics and locale and in 2 churches with primarily African American congregations. The projects utilize a train-the-trainer model where employees and congregants (peers) with a particular interest in health and wellness participate in a thorough educational curriculum and participate in a training program that allows them to serve as HBP ambassadors in their workplace or community group. As peers, trainers are not required to have certification or experience in health care fields. These HBP “ambassadors” then interact on a recurring basis with colleagues who may have HBP or who otherwise wish to learn more about the condition or preventing it, modifying health behaviors, setting reachable goals, and tracking success. At the outset and conclusion of the demonstration projects, participants are being surveyed about their own risks, knowledge, behaviors, and goals. The purpose of these qualitative surveys is to assess whether participants were able to successfully set and reach goals as part of an overall plan to manage their BP. In addition, each location has been furnished a BP kiosk so that participants (and nonparticipants) can easily monitor their own readings confidentially and get quick feedback as their numbers change over time. The coordinators of the demonstration project have access to de-identified data and reporting from the kiosks that will enable aggregation of results over the full course of the projects. The key lessons of the demonstration projects will be to evaluate whether a peer health ambassador or coach model can successfully motivate sustained health behavior change.
The Best Practice Work Group initially focused on recruiting practices to participate in the HBP project and identifying the barriers to successful achievement of BP targets in patients followed in primary care practices. The Work Group focused recruitment on the 3 major health systems’ primary care networks, which employ approximately 40% of Monroe County primary care physicians. Presented with the offer to participate in a county-wide, multi-stakeholder quality-improvement project, all 3 system’s primary care leaders enthusiastically agreed to participate. Together these 3 groups will provide data on 151 internists, 59 family physicians, and 33 mid-level practitioners. Because the high-risk populations for complications of HBP were found to be the elderly, minorities, and the socioeconomically disadvantaged, the 2 federally funded neighborhood health centers serving those constituencies were also recruited. The neighborhood health centers and 2 of the health systems had already migrated to electronic health systems, simplifying the data collection and practitioner reporting components of the program. In all, participants’ practices account for 36% of family physicians and 38% of internists in Monroe County. Together, these practitioners care for 290,000 patients or 49% of the estimated 2008 Monroe County population of 586,000 older than 18 years. To ensure that people in the targeted zip codes will be included in the project, we employed geo-coded mapping using a program from MapInfo (Pitney Bowes Software Inc, Troy, NY) to display the sites of the practices recruited to the project. The second component of the program, identifying the barriers to successful achievement of BP targets in the high-risk population, resulted in a 2-pronged improvement approach. The first prong involved the creation of a community-wide HBP registry that included data from the 3 systems aggregated for a community report, but also shared through the health system and health center’s quality-improvement projects at the individual, practice, and system level. Accurate, meaningful peer-comparison data have been found to be a powerful motivator of physician-level change.
The Best Practice group had to define how BP should be measured to be entered into the registry. Because this is a community-wide project, there was no paid staff to verify BP and the entries were generally made from electronic health record (EHR) data that were recorded from office visits, the Best Practice work group decided to use the most recent BP in the designated timeframe entered into the patient record, be it paper or EHR. There was considerable discussion around the use of home BP measurements, and averaged BPs from multiple office visits but these data were not available from the EHR systems in use and would have significantly increased the costs of the chart reviews conducted on the records from the third participating health system.
The registry, as constructed, provides the important information found in the Figure. The data collected include the number of patients entering the practice in the past 6 months with a diagnosis of HBP (a measure of the Community Engagement Work Group’s success in encouraging those with HBP not in care to seek care), the number of patients seen in practices within the past 3 years with a diagnosis of HBP, the number, and percentage of patients with a diagnosis of HBP not seen in the past 13 months, and the number and percentage of those who are in care and have reached their target BP.
As seen in the Figure, 10% of patients with HBP seen in primary care practices have not been seen in the past 13 months. This group provides a quality improvement opportunity to identify, notify, and encourage those patients to come into the office to assess their success in treatment. In addition, the registry provides baseline control data. For those seen within the past 13 months, 63% have their most recent BP in 2010 recorded as <140/90 mm Hg. This result is similar to what Egan and colleagues2 reported as the national average of 67% for adequate BP control for persons undergoing treatment for HBP. Inserted into the community dashboard, these data let all the stakeholders know that more is needed to reduce the untoward complications of HBP. Even more important, it creates the opportunity for systems to internally compare, practices, and individual practitioners to stimulate competition to improve results. In addition, in the category “patients with HBP seen in nonparticipating practices,” represents an opportunity to identify nonparticipating practices, recruit them to the project, and increase the number of patients for whom there is sociodemographic and BP data available.
Although peer-comparison data create a powerful motivator for change, to achieve results, The Best Practice Work Group determined that more is needed to meet its challenge of improving the control rate to reach the 85% target. As a result, the second prong of the Best Practice Work Group is built around the literature’s suggestion that “Clinical Inertia” is responsible for much of the difference between what can be achieved and what is achieved.16,17 Clinical inertia simply states that although persons with HBP come to practitioner’s offices and have their BP taken and are found to have BP ≥140/90 mm Hg, they leave the visit without a plan for improvement being created. Although there are many good reasons why a practitioner has chosen to ignore the BP or has focused on more pressing issues, the fact is that an important medical problem is left unaddressed.
To address clinical inertia, an Education Work Group was established with an American Society of Hypertension (ASH)–designated specialist as chairman. The work group defined 3 core tasks:
The components of the program involve:
Increasing practitioner knowledge of guideline recommendations through dissemination of information through presentations by national experts, creating a speakers’ bureau for area grand rounds and conferences, attending system primary care meetings, and participating in American College of Physicians and American Academy of Family Physicians regional meetings.
Training a group of individuals to conduct academic detailing meetings with primary care practices interested in improving their BP control rates. Using models of adult learning,17
practice visits focus on eliciting practitioner and staff ideas of how to redesign care to share responsibility and engage the entire staff in reaching quality-improvement goals. This is a core component in supporting the redesign of chronic disease care to more effectively utilize the practice team to define the key steps in helping identify those with HBP, ensuring that information regarding patient’s beliefs, adherence to therapy, and concerns with care are solicited by staff in advance of the visit with the primary care practitioner. After the visit, staff can reinforce therapeutic changes, ask about patient’s agreement and understanding of the recommended treatment, and encourage questions or thoughts to be shared. Empowering the practice team is an explicit goal of the redesign process. This group will include medical doctors as well as other health practitioners including nurse practitioners, physician assistants, and nurses.
Identifying primary care physicians within systems and health centers interested in serving as clinical hypertension experts by studying for and passing the examination to become an ASH-designated specialist in hypertension.
Results shown in the Figure will be refreshed twice yearly and reported in aggregate to the community. The final piece of the multifaceted intervention is to ensure that health plan and employer benefit design supports and encourages therapeutic success. The plan design work group solicits ideas from community organizations and the practice community and negotiates benefit changes with the health plans and employers.