August 2015 Campaign Updates

August 2015 Campaign Updates

Q2 2015 Deadline: September 4, 2015 To report your data, please submit via our portal by September 4: https://members.measureup pressuredown.com/ Questions? Email: mupddataadmin@amga.org

Upcoming Campaign Webinars: September December 2015

IQL Conference: October 21-23, 2015

Call for Resources: October 30, 2015 Contribute resources that successfully empower patients, improve care delivery, or leverage information technology at your organization Approved submissions will be credited to your organization Questions? Email diabetestoolkit@amga.org To learn more or submit your resources, visit: www.amgf.org/diabetes

Call for Resources: October 30, 2015 Requested resources, related to type 2 diabetes, includes: Documents related to successful multi-disciplinary diabetes teams (e.g., charter, scope of work, composition, organizational chart) Patient resources specific to emotional and behavioral support Resources on how to establish a recognized diabetes education and selfmanagement program (e.g., referral criteria, business plan) Treatment algorithm Resources used to identify and conduct outreach to patients overdue for A1c testing (e.g., reports, scripts, letters) Cardiovascular disease risk assessment tool or calculator Patient outreach protocols and related tools (e.g., phone scripts, letters) Resources to conduct practice-based screening Point-of-care tools Patient registry Unblinded performance reports (by site of care, provider, and/or care team) To learn more or submit your resource(s), visit: www.amgf.org/diabetes

Million Hearts Challenge: October 31, 2015

Next National Day of Action: May 5, 2016

Withings Home Blood Pressure Monitoring Pilot Project Overview Shannon Walsh American Medical Group Foundation Program Manager, Chronic Care Initiatives

Home Blood Pressure Monitoring Recent poll shows nearly half of American adults are extremely or very interested in being able to check their own blood pressure on smartphones or tablets. Estimated net savings associated with the use of home BP monitoring range from $33 to $166 per member in the first year and from $415 to $1364 in the long run (10 years). 95% of physicians agreed that home blood pressure measurements were useful in making treatment decisions to manage hypertension patients condition.

Withings Pilot Project Goal The primary goal of the Project, in parallel with the Measure Up/Pressure Down campaign, is to: improve blood pressure control in patients under the care of physician practices.

Additional Project Objectives To identify and document: Success factors in enrolling, engaging, and retaining patients with the device and home BP monitoring Modifications in care processes that increase physician and staff acceptance of engaging patients in their own care Patient and physician/staff satisfaction with home monitoring of home blood pressure

Withings Pilot Project Overview

Withings Pilot Project Limitations

Withings Pilot Project Process Training Patient Recruitment & Enrollment Patient Retention Outcomes Care Process Modifications

Withings Pilot Project Process Training Patient Recruitment & Enrollment Patient Retention Outcomes Care Process Modifications

Withings Pilot Project Device Withings Wireless Blood Pressure Monitor Received FDA approval in 2014 Fully automatic blood pressure monitor, operating on the oscillometric principle Features: Measures blood pressure and pulse rate Stores the measurement results within an iphone, ipad, ipod touch, or Android Synchronizes with a patient s personal Withings account and project portal

Withings Pilot Project Process Training Patient Recruitment & Enrollment Patient Retention Outcomes Care Process Modifications

Withings Pilot Project Participant Criteria 1. Newly diagnosed or existing hypertension 2. Have an iphone, ipad, ipod touch or Android personal device prior to enrollment in the project 3. Agree to use such device during participation in the project and provide access to readings via portal

Withings Pilot Project Process Training Patient Recruitment & Enrollment Patient Retention Outcomes Care Process Modifications

Withings Pilot Project Process Training Patient Recruitment & Enrollment Patient Retention Outcomes Care Process Modifications

Withings Pilot Project Process Training Patient Recruitment & Enrollment Patient Retention Outcomes Care Process Modifications

Withings Pilot Project Analysis

Withings Pilot Project Outcomes Overall Pretest Average Overall Posttest Average All Groups 4.54 4.41 Community Physician Network 4.32 4.49 Cornerstone Health Care 4.74 4.62 Billings Clinic 4.44 4.25 Wilmington Health 4.67 4.48 No statistically significant differences (e.g., pre vs. post or between groups)

Withings Pilot Project Outcomes

Withings Pilot Project Outcomes

Withings Pilot Project Acknowledgements Billings Clinic (Billings, MT) Project Leads: Elizabeth Ciemins, PhD, MPH, MA & Barb Holloway, RN, CDE Advisor: Robin Garland, NP Community Physician Network (Indianapolis, IN) Project Leads: Leisa Hills, RN, MSN & Nick Sciacca, PharmD, BCACP Advisor: Michael Baach, MD Cornerstone Health Care, P.A. (High Point, NC) Project Leads: Scott Cecil, MAS, Gezelle Macon, & Kyle Nifong, MBA Advisor: Susan Payne, GNP-BC Wilmington Health (Wilmington, NC) Project Lead: Holli White & Sandy Harris Advisor: Jonathan Staub, MD

Integrating Home Blood Pressure Monitoring into Primary Care Practice: A Pilot Study Barbara Holloway, RN, BSN, CDE Elizabeth Ciemins, PhD, MPH, MA August 20, 2015 www.billingsclinic.com

Study Objective To improve the monitoring, management, and control of hypertension by: identifying high risk patients with the diagnosis of hypertension; engaging patients in discussion and education about their disease; promoting self monitoring using an automated wireless blood pressure measurement device; expanding the use of the EHR to manage disease

Specific Aims Aim 1: Identify patients with newly diagnosed or uncontrolled hypertension, engage patients in disease management education, and to supply patients with an electronic, wireless oscillometric monitor for home blood pressure measurements. Aim 2: Retrieve the automatic blood pressure reading values from the device manufacturer s data base, and alert the patient s primary care provider of any out of range values.

Recruit 37 patients Methods Provide education and home monitors Follow patients for 4-7 months Assess blood pressure change over time Monitor provider behavior through chart review Survey patients on ease of use, perceived effect on outcomes, engagement, and perceived quality and accuracy of device

Recruitment and Workflow Recruitment sources for 37 participants: 24 primary care provider 1 Billings Clinic newsletter 6 Employee Board notification 5 calls to patients with HTN with scheduled office visit 1 physician self-referred RN navigator interviewed and educated prospective participants and issued monitors Reviewed Withings site once per week and noted the high, low and median values

Recruitment and Workflow (cont.) Readings sent to nurse practitioner (NP) NP determined if PCP should be notified NP provided f/u appointment date if applicable RN navigator fielded questions from participants, called to remind to take BPs more often if appropriate, or provided technical assistance or education

Demographics (n=37) Measure mean range Age (years) 55.4 28-78 BMI (kg/m 2 ) 32.3 20-45 Length in Study (months) 4.8 0.4-6.7 n % Female 18 49 White 35 95 Hypertension Diagnosis 32 86 Diabetes Diagnosis 5 14 Chronic Kidney Disease Diagnosis 3 8

Provider Plan Specialist for HTM management 1 (3) Dietitian, Educator, or other care provider 2 (5) Hypertension Medication Action n (%) Started or added medication 13 (35) Increased dose 8 (22) Decreased dose 3 (8) Discontinued medication 7 (19) Lifestyle Change Action n (%) Instructed participant to return for nurse re-check 16 (43) DASH or other diet plan? 25 (68) Recommended weight loss, exercise or other lifestyle changes 25 (68) Referrals n (%)

Blood Pressure Control Baseline Study Completion Controlled BP 51% 68% Definition of Controlled Blood Pressure: < 140/90 < 150/90, if age 60+

Patient Survey Perceived Ease of Use PRE POST Confidence in Ability to Use or Having Used the Device Correctly 4.54 4.53 Device Will Be, or Was, Easy for Patient to Use 4.37 3.91 The Instructions I Received on How to Use the Device Were Comprehensive 4.56 4.59 I Learned How to Use the Device 4.51 4.38 Connecting the Device to the Phone Will Be, or Was, Easy for Me to Do 4.41 4.09 Perceived Effect on Outcomes Device Will, or Did, Improve Patient's Ability to Monitor and Control Blood Pressure 4.46 4.28 Use of the Device Will Enhance, or Is Enhancing, the Ability of My Provider and me to Improve my Blood Pressure Control 4.65 4.22* I Will, or Did, See Improvements in My Blood Pressure Through Using the Device 3.92 3.94 I Will, or Am, Monitoring Blood Pressure More Often with the Device 4.65 3.88* 1 = Strongly Disagree, 5 = Strongly Agree

Patient Survey (cont.) Effect on Patient Engagement I Will, or Do, Feel More Confident in My Provider's Ability to Help Me Control My Blood Pressure Once Using the Monitor Use of the Device Will, or Did, Improve Communications with My Provider Regarding My Blood Pressure I Will, or Do, Feel More Comfortable in My Ability to Improve My Health Through Using the Device PRE POST 4.43 4.00* 4.62 4.13* 4.24 4.25 The Device Will, or Did, Improve My Motivation to Try to Control My Blood Pressure 4.54 4.28 Perceived Quality and Accuracy of Product Blood Pressure Results Obtained Through the Device Will Be, or Were, About What Was Expected 4.14 4.25 The Device Will, or Does, Give Me Clear Feedback on My Blood Pressure Level 4.54 4.50 I Expect to, or Do, Recommend the Device to People Who Are Trying to Monitor Their Blood Pressure Level 4.08 4.13 Use of the Device Will Not, or Did Not, Intrude On or Disrupt My Personal Life 4.46 4.25 The Blood Pressure Results Obtained Through the Device Will Be, or Were, Clear 4.49 4.56

Participant Comments Likes Asked to keep the meter and continue to work with PCP (n=25) Learned what effect exercise, food, or stress has on BP Reported PCP more responsive to discussing HTN and problem-solve with them Dislikes Did not trust readings Trouble with app or Bluetooth C/O pain with readings Trouble with reading errors or monitor stopping often Green light had to be manually turned off Too bulky to travel with Button too small for large hands.

68 yo female Success Story #1 Could not convince PCP about her widely fluctuating BP values (108/60 184/87) Took her phone in to office visit with the Withings graph Convinced PCP to order a specialist consultation and problem-solve with patient

Success Story #2 59 yo male Surprised by extreme readings on intake Sent home with monitor & told to check several more times and call PCP if high readings continued Found that his medication bottle had been filled with a statin at the pharmacy Corrections made and he is very happy with the monitor.

Summary Home monitoring has the potential to improve HTN management among patients with uncontrolled or newly diagnosed HTN Technology needs to be easy to use and operate, and integrated into local EHR Home monitoring has the potential to improve provider-patient engagement in HTN management

Questions? Barbara Holloway: bholloway@billingsclinic.org

Community Physician Network Withings Home Blood Pressure Monitoring Pilot Leisa Hills, RN, MSN Director Clinical Excellence Nick Sciacca, PharmD, BCACP Clinical Pharmacist Specialist

About CPN Community Health Network 8 hospital health Network serving central Indiana CPN multi- specialty group practice with ~ 600 providers in over 200 locations Primary Care ~ 250 providers in 80 locations

Care coordination models IPCT (Integrated Primary Care Team) 9 teams located in hubs in Network pavilions to allow multiple practices to utilize Team consists of Complex Care RN; Clinical Pharmacist, Dietician, Social Worker Provide comprehensive assessment and care plan for high and moderate complexity patients with co-morbidities and poly-pharm

Withings Home BP monitoring pilot Patient Recruitment : Pre-visit chart review for potential uncontrolled HTN patients Newly diagnosed HTN patients at office visit Optum One data list of uncontrolled HTN patients attributed to provider Enrollment of 37 patients occurred between 10-14-14 and 12-12-14 (~59 days)

Enrollment Flowsheet MA/RN adds poss. BP cuff to appt. notes for those whose last BP above goal RN/MA rooming patient asks qualifying questions If qualifies, MA/RN informs physician RN or PharmD completes all necessary enrollment steps If patient accepts, staff member informs PharmD or RN involved in program enrollment If physician feels good candidate, offer/explain program to patient

Patient Enrollment Enrollment and patient teaching a lengthy process, allow for staff time to complete Allowed patient to keep device after pilot was an enticement to enroll RN or PharmD enrolled and downloaded app while in office RN or PharmD then became technical support for patients was time consuming

Participant Flowsheet Patient instructed to check BP daily at home with cuff RN reviews half patient list (18 patients) once weekly Average BP above goal? PharmD communicates plan to PCP/patient PharmD makes changes using agreed upon protocol or makes recommendation to PCP regarding drug therapy / labs Phone note to PharmD to investigate by call to patient / pharmacy (adherence, SE, etc.)

Workflow and care process changes Pre-visit chart reviews Dedicated staff to pull portal results, document in EMR and follow up on out of range readings Dedicated staff to trouble shoot/technical assistance Med adjustment by PharmD per protocol Downloaded portal and added to favorites for all staff accessing portal

Outcomes 12-12-14 successfully enrolled 36 patients 26/36 portal results show BP in control BP in control Plan: Download readings every 2 weeks Document readings in EMR Touch base with patient let them know in control and to keep monitoring

Non-controlled patient plan 10/36 portal results show BP not in control - Download all patient readings every 2 weeks - Calculate average 2 week readings in excel - Determine med changes per protocol - Send readings/med changes to provider in EMR note - Monitor readings weekly looking for positive change in 2 weeks, expect control within 4 weeks

Positives outcomes Patient engagement Increasing patient understanding of team based care Improved BP readings in many enrolled patients Increased provider satisfaction/buy-in of team based care model

Challenges Staff time to enroll/trouble shoot/monitor/follow-up Technical issues with Smartphone and Android load Battery life in Withings device short Withings cuff had size limitations Some patients stopped monitoring: Device issues BP in control

Lessons learned Provider buy-in and support critical Dedicated staff to enroll, trouble shoot, pull results from portal and evaluate, document and follow up with provider treatment plan