Essentia Health Duluth Clinic RN Hypertension Management Pilot

Transcription

1 Hypertension Best Practices Symposium Sponsored by AMGA and Daiichi Sankyo, Inc. October 13-15, 2010 Scottsdale, AZ Essentia Health Duluth Clinic RN Hypertension Management Pilot 1

2 1888:St. Mary s Hospital founded 1915:Duluth Clinic established 1997:SMDC Health System launched with integration of St. Mary s and Duluth Clinic 2010: SMDC Health System, Innovis Health, Brainerd Lakes Health, and Essentia Community Hospitals and Clinics form integrated healthcare system called Essentia Health 400,000 + annual patient visits at the Duluth EMR: EPIC 2

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4 Goals & Objectives Increase the percentage of patients with a diagnosis of hypertension and diabetes that have a BP < 130/80 Improve patient education, self-management skills and lifestyle choices associated with the management of hypertension 4

5 Why RN-Focused Management? Effective management of hypertension requires systematic and coordinated patient care management. A multidisciplinary team-based approach can influence and reinforce goals and ensure adherence. Literature supports RN participation in hypertension as a matter of course. It is not instead of physicians, but complementary. Research also demonstrated that RN management of HTN in collaboration with physician is superior in BP control to standard office-based management.

6 Population Baseline Patients ages who have concurrent diagnosis of Diabetes Mellitus ( Dx code )and hypertension Two Pilot Sites Identified from patient registry within EMR and physician referral 6

7 Improvement Interventions 1d/wk dedicated RN Care Management to work with two physician patient panels at each site. Established referral process with physicians Hypertension standing orders/medication management protocol Patient registry 7

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10 Improvement Interventions Optimization of pharmacologic and non-pharmacologic therapies consistent with JNC 7: Shorten time between follow-up for pts Assess effectiveness of current medication regimen with ability to titrate dose and/or add medication per protocol Individualized patient education re: lifestyle modification

11 Assessment and Development of Treatment Plan Education of patients re: target blood pressure and the importance of achieving and maintaining this target. Self/home blood pressure monitoring techniques and appropriate equipment. (BP cuffs provided as $$ allowed) Identify lifestyle factors that influence hypertension management, recognize potential areas for change and create a collaborative management plan.

12 Lifestyle Interventions A combination of lifestyle interventions is often needed to achieve optimal blood pressure values Diet, weight, exercise, smoking, alcohol consumption and stress are lifestyle factors that impact on blood pressure. Some lifestyle interventions have the potential to decrease blood pressure levels to the equivalent of a half to one standard dose of an antihypertensive drug Example: For some individuals, a 1600 mg sodium DASH eating plan has BP effects similar to single drug therapy. (JNC 7)

13 Lifestyle Interventions Partner with patient to create My Change Plan with S.M.A.R.T goals Specific Measureable Attainable Realistic Timely Motivational Interviewing training for RN staff Referrals when appropriate (Weight Management, QuitPlan, Dietician) Assess adherence to medication (side effects, financial concerns, etc.)

14 Medication Titration Protocol designed for hypertensive pts with diabetes Initiate/titrate dose per algorithm Step 1: ACE Inhibitor Step 2: Add thiazide diuretic Step 3: Add dihydropyridine calcium channel blocker Each step in protocol includes required labs, follow-up intervals, contraindications, relative contraindications, cautions and guidance as to MD consultation All changes documented and provider informed

15 Measures Used National Institutes of Health (2003). The seventh report of the Joint National Committee: Prevention, detection, evaluation and treatment of high blood pressure. JNC 7. Institute for Clinical Systems Improvement (ICSI). Diagnosis and Management of Type 2 Diabetes Mellitus in Adults.14 th edition, July Institute for Clinical Systems Improvement (ICSI) Hypertension Diagnosis and Treatment. 12 th edition, October

16 Snapshot of RN-Managed Patient Cohort Essentia Health- Ashland Clinic :Site 1 n=55 Average age: 64 yrs 54% male 56% female 91% non-smokers 87% on daily ASA

17 Snapshot of RN-Managed Patient Cohort Average BMI = 35 All Patients n= 89,760 2% underweight (< 18.5) 1% 4% normal weight ( ) 25% 18% overweight ( ) 33% 29% Obese Class I ( ) 23% 22% Obese Class II ( ) 11% 25% Extreme Obesity (>=40) 7%

18 Snapshot of RN-Managed Patient Cohort Medication Management 0 Meds 4% 3 Meds 29% 1 Med 20% 4 Meds 13% 2 Meds 34% Drug Classification 71% patients on ACE 9% patients on ARB 33% patients on Calcium-channel blocker 49% patients on Beta-blocker 58% patients on diuretic

19 Challenges Time constraints, 8 hours per week Clear referral process Patients not fitting titration protocol Fragmented care between providers Multiple physicians (specialists) adjusting medications Reimbursement for RN visits the average unadjusted 2009 payment from Medicare for a service was $21. Ambivalence by patients. My blood pressure is fine. Engaging patients to follow through on lifestyle changes Medication confusion, adherence and cost Physician agreement with existing/evolving guidelines Obesity 19

20 Outcomes and Successes Key elements to success: Cooperative management with pilot physicians Follow- through and coaching Team work with ancillary staff PSA s who contacted and scheduled patients that were due for follow up. RN s who took opportunities at other appointment to check a BP CA s who took BP s and handled referrals Increased patient satisfaction 20

21 RN Managed Hypertension Pilot Site 1 and 2 October August Oct-09 Aug-10 Average Systolic/ Site 1 Average Systolic/Site 2 Average Diastolic/Site 1 Average Diastolic/Site 2

22 100 Percent of Patients Referred to RN- Managed HTN Pilot Program with BP < 130/80 Baseline - Current (August 2010) n= 107 % of patients in pilot group with BP < 130/ Site 1 n=55 Site 2 n=52 Site 1 & 2 n=107 10/1/2009 Baseline 8/1/2010 Current

23 Lessons Learned As confidence increases in medication titration and RN management we could anticipate increased improvement in outcomes Avoid missed opportunities to assess BP and modify treatment as appropriate Example: Pt calling for HTN med refill: Length of refill determined by pt meeting or not meeting tx goal Team approach essential It cannot all happen in a 15 minute MD appt Collaborate with pt to set goals Patients have ability to veto any advice as soon as they leave the clinic. 23

24 Future Steps More data needed to assess value of intervention. Improvement can be attributed to many different factors in place over last 6-9 months. Addition of pharmacist/medication Management 24

25 Questions Do you have any questions you d like to pose to the group? 25

26 Bibliography AHA/ADA Scientific Statement: Primary Prevention of Cardiovascular Diseases in People with Diabetes Mellitus American Heart Association Quick Reference Medication Table Canadian Hypertension Society (2004). The 2004 CHEP recommendations for the management of hypertension. Canadian Hypertension Education Program. Retrieved [Electronic Version] from Canadian Hypertension Society (2005). The 2005 Canadian Hypertension Education Program Recommendations. Retrieved [Electronic Version] from: Canadian Medical Association (1999). Lifestyle modifications to prevent and control hypertension. Canadian Medical Association Journal, 160(9 Suppl), S1-S50. Fonseca-Reyes, S., Garcia de Alba-Garcia, J., Parra-Carrillo, J., & Paczka-Zapata, J. (2003). Effect of standard cuff on blood pressure readings in patients with obese arms. How frequent are arms of a large circumference? Blood Pressure Monitoring, 8(3), Graves, J., Bailey, K., & Sheps, S. (2003). The changing distribution of arm circumferences in NHANES III and NHANES 2000 and its impact on the utility of the standard adult blood pressure cuff. Blood Pressure Monitoring, 8(6), Institute for Clinical Systems Improvement (ICSI).Diagnosis and Management of Type 2 Diabetes Mellitus in Adults.14th edition.july Institute for Clinical Systems Improvement (ICSI) Hypertension Diagnosis and Treatment. 12th edition. October National Institutes of Health (2003). The seventh report of the Joint National Committee: Prevention, detection, evaluation and treatment of high blood pressure. JNC 7. National Institutes of Health. Retrieved [Electronic Version] from Nurse Management for Hypertension: A Systems Approach. Rudd, et.al. American Journal of Hypertension Staged Diabetes Management: Prevention, Detection, and Treatment of Diabetes in Adults Quick Guide, 4th edition, IDC Up to Date/Drug Information Handbook. Lexi-Drugs. 14th edition Williams, B., Poulter, N., Brown, M., Davis, M., McInnes, G., Potter, J. et al. (2004). Guidelines for management of hypertension: Report of the fourth working party of the British Hypertension Society, 2004 BHS IV. Journal of Human Hypertension, 18(3),