Community-Based Hypertension...

Community-Based Hypertension Management SRMC Team: HLLC, SPN, SRMC-SON & VDH

SYNC CAPSTONE TEACHBACK: NOVEMBER 10, 2017

We, the Southside Regional Medical Center team,

DO NOT have a financial interest/arrangement or affiliation with one or more organizations that

could be perceived as a real or apparent conflict of interest in the context of the subject of this

presentation.

Disclosure Statement of Financial Interest

Southside Physicians Network (SPN)• Angelica Smith, MSN, NP-BC

Southside Regional Medical Center - Professional Schools (SRMCPS)• Dr. Katherine Lawson, DNP, RN

Southside Regional Medical Center• Lisa Mears, BSN, RN

Crater District Health Departments• Dawn Pittenger, MPH, CHES

Healthy Living and Learning Center - Petersburg Public Library• Robert Noriega, MS

1. Team

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•Hypertension (HTN) is the most common primary diagnosis in America.

•35 million office visits are as the primary diagnosis of HTN.

•85 million or more Americans have high blood pressure (BP).

•Worldwide prevalence estimates for HTN may be as much as 1 billion.

•7.1 million deaths in the U.S. per year may be attributable to hypertension.

Background

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Development, implementation, and expansion of a sustainable program to address elevated blood pressure among adults at-risk or diagnosed with hypertension in our shared community.

2. Focus

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• Hypertension is a significant population health concern among adults in the shared service district.

• Effective, evidence-based, low-cost interventions are needed to improve health.

• Lessons learned from implementation of this program may be useful in targeting future efforts to address both hypertension and other chronic diseases.

3. Need

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• Review, refine, and evaluate SYNC 2016 outcomes.

• Implement BP screening developed in SYNC 2016.

• Collect data for shared measurements.

4. Objectives

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• Measure 1: % adult patients with high blood pressure in adherence to medication regimen.

• Measure 2: % of patients with high blood pressure that have self-management plan.

• Measure 3: % simple BP control. Patients 18-85 years of age who have diagnosis of HTN and whose BP is equal or less than 140/90 during the measurement period.

4. Selected Project Measures

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Programs• VDH grant.• AHA Heart360® and Check.Change.Control® programs.

Locations

• Tabernacle Baptist Church Health Ministry.

• Healthy Living and Learning Center at the Petersburg Public Library.

People

• SRMCPS nursing students who are eager learners and volunteers.

• SPN community outreach - SRMC transition coalition.

5. Assets

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• Engaged and connected with community resources.

• Consolidated current programs and goals.

• Evaluated other programs to improve current systems.

• Pilot Intervention.

6. Action Strategies

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This is a build up from previous year• Gathered the right team. • S.W.O.T. Analysis.• Planned and executed project.• Implemented Check.Change.Control® through Tindall

Wellness Clinic and SPN primary care.

• Evaluated lessons learned.

7. Team Development

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Gathered the right team • VDH• SRMC – Transition Coalition• SPN – Primary care• Healthy Living and Learning Center• SRMCPS – Nursing students

7. Team Development

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S.W.O.T. Analysis• Strengths: Motivated team with common goal.• Weakness: Need for centralized system.• Opportunities: Check.Change.Control®.• Threats: Unknown receptibility of technology presented.

7. Team Development

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• Planned and executed project.• Implemented Check.Change.Control® through Tindall.

Wellness Clinic and SPN primary care.

• Evaluated lessons learned.

7. Team Development

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Check.Change.Control®

• Self management tool by AHA.

• At no-cost to participants.

• Empower participants to take ownership of their HTN.

• Incorporates remote monitoring, online tracking, and local volunteer health mentors.

7. Team Development

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Check.Change.Control®

• Self management tool by AHA

• Free of charge

• Empower participants to take ownership of their HTN.

• Incorporates remote monitoring, online tracking, and local volunteer health mentors.

7. Team Development

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Diverse settings

•Employee wellness clinic – Tindall Wellness Clinic

•Primary care – SPN-PC

•Community based resource – Tabernacle Baptist Church Wellness Ministry

Site selection

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Tindall Wellness Clinic• Employee wellness clinic• 236 patients• 80% Hispanic (regardless of race), 10%

Black/African American, 7% White/Caucasian, 3% Other

• 72% have HTN with medication regimen• Pre-intervention 56% at goal • 76% compliant

The 3 clinics/sites overview

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SPN Primary Care• Primary care setting• 5,036 patients • 46% Black/African American, 40% White/Caucasian,

11% Hispanic, 4% other• 69% have HTN with medication regimen• Pre-intervention 52% at goal • 72% compliant

The 3 clinics/sites overview

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The 3 clinics/sites overview

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Tabernacle Baptist Church• Church ministry wellness program• 30 participants• 100% Black/African American• 100% have HTN• Pre-intervention 43.46% at goal• 69.23% compliant

• Simultaneous launch at SPN and Tindall Spring 2017

• Evaluation of SPN and Tindall Summer 2017

• Plan and execution of Tabernacle Baptist Church Fall 2017

• Follow up Spring 2018

8. Testing & Refinement

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Planned and executed pilot• Formative evaluation• Process evaluation

In Progress: • Outcome evaluation• Impact evaluation

8. Testing & Refinement

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•76 participants•Post-intervention 20% improved to goal, now at 76%.•Main issue reported pre-intervention was forgetting taking medication (10%) and forgetting picking up medication from the pharmacy (7%).•Post intervention main issue reported was forgetting taking medication (5%) and forgetting picking up medication from the pharmacy (2%).•Most participants (89.97%) agreed that text message reminders helped them be compliant with their medication regimen.

9. Results to Date: Tindall

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•106 participants•Post- intervention 19% improved to goal, now at 71%.•Main issue reported is forgetting taking medication with them when traveling (6%), Forgetting taking medication (5%), and forgetting picking up medication from the pharmacy (2%).•Post intervention main issue reported was forgetting taking medication (1.5%) and forgetting picking up medication from the pharmacy (2%).•Most participants (79.87%) agreed that text message reminders helped them be compliant with their medication regimen.

9. Results to Date: SPN-PC

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•26 participants

•Pre intervention - initial blood pressure reading average of 142/76.•Only 13 (46.43%) participants were at goal. •15 participants (53.57%) with BP 140/90 or greater.

• 69.23% compliant

9. Results to Date: Tabernacle Baptist Church

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Tabernacle Baptist Church: Pre-intervention

•Main issue reported pre-intervention were forget to take medication (29%) and difficulty getting transportation to the pharmacy (5.7%).

•Pre-intervention most participants (92%) value community based programs that help them monitor their blood pressure.

9. Results to Date: Tabernacle Baptist Church

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•Implement changes and continue with pilot.

•Finalize site contracts and incorporate nursing students.

•Post- intervention will be accessed 6 months post intervention.

•Based on results will further refine and adjust program.

•Reach out other markets – expansion.•PCPs

•Church ministries

•Wellness organizations

What’s next?

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• Need for common language.

• Inter-disciplinary scheduling presents a problem.

• Communication, dedication, and intrinsic motivation are key to success.

10. Lessons Learned

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Any Questions?

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