By Al Bradley, Finger Lakes Health Systems Agency, Nancy M. Bennett, MD, Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester, New York
For the past nine years, the Rochester Business Alliance (RBA) – the chamber of commerce for the Rochester, New York/Finger Lakes region – has taken an active role in healthcare issues. The region’s largest employers formed the Health Care Planning Team to formulate strategies that would improve health and reduce costs. They were instrumental in implementing a community-wide employee wellness program, “Eat Well Live Well,” to encourage physical activity and consumption of fruits and vegetables; and were a primary driver in the launch of the regional health information organization (RHIO), one of the highest performing RHIOs in the country.
In 2009, the Health Care Planning Team began to explore projects that would promote greater change across the community, accelerate that change, address specific conditions that community data indicated were consistent challenges, and expand participation. After further analysis as well as multiple key informant interviews, the team decided to focus on high blood pressure. An estimated 30 percent of American adults suffer from high blood pressure; national control rates are far below desired targets; and failure to gain control can lead to devastating outcomes.
In 2010 the Health Care Planning Team forged a partnership with the Finger Lakes Health Systems Agency (FLHSA) to create the FLHSA/RBA High Blood Pressure Collaborative, which includes all major local healthcare systems, the business community, community-based organizations, the faith community, physician groups and insurers, to collectively formulate a multi-faceted set of interventions anchored in Wagner’s model of chronic care.
Because of the deliberately diverse nature of the collaborative, it was natural to focus interventions on a variety of aspects (healthcare, worksite, and community). The collaborative specifically designed multi-faceted initiatives that would promote behavior change, improve adherence to care plans, and increase self-management of health.
Measurement of Practice and Community Performance
Representatives of the collaborative approached the major local health systems, Federally Qualified Health Centers and larger primary care groups to request sharing of high blood pressure patient data. All were eager and willing to participate in this important initiative. Two times per year, these partners submit de-identified data to healthcare analysts at the Finger Lakes Health Systems Agency. These data include information on all patients identified by a problem list or ICD-9 code as having high blood pressure. The data also include the most recent blood pressure reading, from which analysts calculate control rates across demographic variables, co-morbidities and socio-economic status. The metrics that emerge are shared with practices that submitted the data and enable comparison across the community and identification of patients for further attention.
Healthcare System Change
Patient care in the clinical setting remains at the center of chronic disease management. Practice reports illustrate for clinicians their practice’s performance including metrics that demonstrate their own performance compared to the entire community. The reports also include recommendations to improve control rates, drawn from the evidence base and experience. The data are further used by a team of “practice improvement consultants” –community clinicians trained in an academic detailing model – who serve as resources to help formulate and implement strategies to improve practice control rates. These strategies include effective use of registries, aggressive patient follow-up and close adherence to guidelines.
A key evolving component of primary care transformation involves practice teams where all staff are empowered to participate in care. Blood Pressure Advocates, trained and supervised by the Center for Community Health, follow a community health worker model and are embedded in practices that have a large number of low income and/or Medicaid patients. The advocates work with the clinical team to identify patients in need of help in blood pressure control, and provide peer-to-peer counseling including education about high blood pressure and healthy behaviors. The advocates also seek to help patients identify and address the key barriers to their blood pressure control. They then share these barriers with clinicians and work together to address them. As members of the patients’ communities, the advocates have knowledge of local resources that can further help in reaching blood pressure control, physical activity and nutrition goals.
In one example, a patient met with the advocate, who found that the patient didn’t have enough money to pay for the co-pays on three different blood pressure medicines and was having difficulty remembering to take the medicines on schedule. The advocate worked with the clinician to revise the treatment plan to a single prescription that the patient only had to take once a day, which also cut copays. From then on, the patient was much more adherent and his blood pressure was well-controlled.
Worksite Health Change
A workgroup of employee wellness experts developed an online worksite wellness index, adapted from a similar CDC tool, to evaluate and improve workplace environments and policies and to provide information on local wellness resources. This team of experts further acts as a resource to smaller employers seeking to implement wellness programs.
Eighty different worksites have completed the index and most report that they are in the process of adopting changes that the index helped identify. These worksites will be encouraged to complete the index again after approximately one year to assess improvements. The lessons learned will be further disseminated to provide a forum for information and strategy sharing.
In addition, one local grocery store chain is deploying pharmacists to provide counseling for their own employees on blood pressure management. Participants have demonstrated improved blood pressure control, weight loss, and are highly engaged. This model is being piloted with other employers.
Community Health Change
At the community level, some of the biggest impediments to blood pressure control are awareness and motivation. To better educate and mobilize those with high blood pressure, the collaborative implemented the Blood Pressure Ambassador Program.
Blood Pressure Ambassadors are partnered with organizations including churches, barber shops, beauty salons, community based organizations and nursing schools. As fellow congregants or constituents, ambassadors are able to establish a high level of trust to increase success in helping promote desired changes in self-management. Ambassadors are provided with tools, resources and training by the collaborative to effectively reach people over a sustained period of time. To promote overall awareness and to increase the number of people who know they have high blood pressure, ambassadors also conduct screening events across a broad spectrum of community venues.
Outcomes of a Communitywide Initiative
The multi-faceted set of initiatives has demonstrated results in improving blood pressure control. Registry data from December 2010 showed a community control rate of 62.7 percent. In December 2013 the control rate improved to 71.3 percent. Ultimately the collaborative will seek to demonstrate improvements in the incidence of cardiovascular events and kidney failure that are often linked to poor blood pressure control.
The key to the success of the Rochester High Blood Pressure Collaborative lies in the ongoing commitment of over 160 individuals from 67 organizations. Collaborative partner forces have come together to take on a common goal. This model can be replicated to take on other health challenges in the future.