Detect.Connect.Control.Preventing a Million Together

NLA Spring Clinical Lipid UpdateFebruary 27, 2015

• Million Hearts overview• Progress report• Detect.Connect.Control.

– Hypertension Cholesterol: Questions for You

Agenda

• What is working in cholesterol management?• What is missing?• Who’s on the Design Team to fill key gaps?• Who are the Implementers?• How quickly can we act?

Hypertension CholesterolQuestions for You

Million Hearts®

• National initiative co-led by CDC and CMS• In partnership with federal, state, and private

organizations

4

Goal: Prevent 1 million heart attacks and strokes by 2017

Key Components of Million Hearts®

Keeping Us HealthyChanging the context

Excelling in the ABCSOptimizing care

Prioritizing the ABCS

Health tools and technology

Innovations in care delivery TRANS

FAT

Health Disparities

Preventing a Million: Targets for the Environment

Intervention Pre-InitiativeEstimate 2017 Target

Smoking prevalence 26% 10% reduction

Sodium reduction 3580 mg/day 20% reduction (~2900 mg/day)

Trans fat reduction 0.6% of calories 100% reduction

National Survey on Drug Use and Health, National Health and Nutrition Examination Survey

Preventing a Million: Targets for the ABCS

Intervention Pre‐InitiativeEstimate*

2017 Population‐wide Target

2017 ClinicalTarget

Aspirin when appropriate 54% 65% 70%

Blood pressure control 52% 65% 70%

Cholesterol management 33% 65% 70%

Smoking cessation 22% 65% 70%

National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey* 2009-2010*2009-2010, National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey

• Engagement and activation• Clinical Quality Measure alignment• Understand what works, where, and why• Resources that help• Focus on what makes a difference

Million Hearts Progress to Date

>110 partners, 50 states, >53K e‐subscribers, 110 Congregations>110 partners, 50 states, >53K e‐subscribers, 110 Congregations

Progress: Addressing Health Disparities

• CDC-Association of State and Territorial Health Officials Million Hearts® Hypertension Control Project• Ohio improved control among African American males

• CMS’ Quality Improvement Organizations• Special projects in 3 states, 1.9M patients, 400+ practices

and partners has led to QIO-wide priority in 2015.• Community and faith-based organizations

• NAACP, National Alliance for Hispanic Health, South Asian Heart Center

• “100 Congregations” for Million Hearts®

• PCORI funding

• Engagement and activation• Clinical Quality Measure alignment• Understand what works, where, and why• Resources that help• Focus on what makes a difference

Million Hearts Progress to Date

As of July 2013

Quality MeasurePQRS/NQF Medicaid Meaningful

Use

HRSA Uniform

DataSystem

VA

PQRS CV Prevention Measures

Group

PQRS GPRO

CMMI Comp

Primary Care

ACOs

Aspirin204/0068

Stage 1 optionalSt 2 opt

#30

BP Screening 317 #21

BP Control236/0018

St 1 optSt 2 core #28

Cholesterol Control 316

St 2 opt

Cholesterol Control in Diabetes 2/0064

St 1 optSt 2 opt

Cholesterol Control in IVD 241/0075

St 1 optSt 2 opt #29

Smoking Cessation226/0028

St 1 coreSt 2 core #17

Progress: Aligning Measures across Programs, 2014

These measures will be replaced with a guideline-congruent measure in 2016 PQRS and other programs

• Engagement and activation• Clinical Quality Measure alignment• Understand what works, where, and why• Resources that help• Focus on what makes a difference

Million Hearts Progress to Date

Champions, AMGA MUPDChampions, AMGA MUPD

2013 Million Hearts®

Hypertension Control Champions

• Dr. Luz Ares, Broadway Internal Medicine; Queens, NY • Cheshire Medical Center/Dartmouth-Hitchcock; Keene, NH• Dr. Jen Brull; Plainville, Kansas• Dr. Nilesh V. Patel; Audubon, PA• Pawhuska Indian Health Center; Pawhuska, OK • Kaiser Permanente Northern California• River Falls Medical Clinic; River Falls, WI• ThedaCare; Appleton, WI• Veterans Health Administration

9 ChampionsSolo to 70,000 Clinicians

8.3M People3.4M with Hypertension

~81% Control Rate

High Performers’ Secrets to Success• Make hypertension control a priority • Deploy a team—working off the same playbook

– Use an evidence-based protocol– Connect to community resources that help people achieve & maintain

control • Use the EHR as a tool for quality

– Maintain a registry of those with hypertension and proactively reach out to those uncontrolled

– Return timely performance data to the team—and the patient– Provide a patient portal for prompt exchange of readings and advice– Comb through EHR data for those “hiding in plain sight”

• Eliminate/minimize obstacles to good control– Teach self-monitoring and good technique to staff and patients– Prescribe 90 day; simplify regimen; encourage mail-order and pillboxes– No cost-share for BP checks

• Recognize and reward patients and staff

• Engagement and activation• Clinical Quality Measure alignment• Understand what works, where, and why• Resources that help• Focus on what makes a difference

Million Hearts Progress to Date

Guides, Healthy Eating Center, CQM Dashboard, Protocols

Guides, Healthy Eating Center, CQM Dashboard, Protocols

Million Hearts® Clinical Quality DashboardPerformance on ABCS

http://millionhearts.hhs.gov/aboutmh/cqm_dashboard.html

Million Hearts® ProgressOptimizing Care – Performance on ABCS

State Level Data available from HEDIS, UDS, PQRS

http://millionhearts.hhs.gov/aboutmh/cqm_dashboard.html

“Dashboard” approach shows progress in ABCS by geographic area

Red = 0%-49%; Yellow = 50%-69%; Green = 70%+; Grey = no data available

• Engagement and activation• Clinical Quality Measure alignment• Understand what works, where, and why• Resources that help• Focus on what makes a difference

Million Hearts Progress to Date

6.3M fewer smokers10M more BPs under control20% less sodium each day

Focus on those with the greatest burden and at the greatest riskStill committed to aspirin, cholesterol, and trans‐fat

6.3M fewer smokers10M more BPs under control20% less sodium each day

Focus on those with the greatest burden and at the greatest riskStill committed to aspirin, cholesterol, and trans‐fat

Where Are We Now and Where Do We Aim?

InterventionPre-Initiative

Estimate(2009-2010)

2017 Population-wide Goal

2017 ClinicalTarget

Aspirin when appropriate 54% 65% 70%

Blood pressure control 52% 65% 70%

Cholesterol management 33% 65% 70%

Smoking cessation 22% 65% 70%

National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey

19

2013 Hypertension Control RatesHRSA Clinics: 63.6% IHS Clinics: 59%

Large Groups reporting via GPRO: 62%HEDIS: 56‐64%

0

5

10

15

20

25

30

35

Milli

ons

35 M People with Uncontrolled Hypertension by Selected Characteristics

6

≥2 1 None

# Times Received Care in Past Year

Yes No

Health InsuranceYes No

Usual Source of Care

Source: National Health and Nutrition Examination Survey 2009-2012.

89% 85%

74%

Standardized Treatment Protocols Can Help Reduce Disparate OutcomesKaiser Permanente Southern California

Sim, et al. Systemic Implementation Strategies to Improve Hypertension: The Kaiser Permanente Southern California Experience. Canadian Journal of Cardiology 30 (2014) 544‐552

“To help ensure homogeneity of practice delivered, the hypertension treatment had to be standardized as well. This meant that an internal treatment guideline was needed.”

Standardized Treatment Protocols Can Help Reduce Disparate OutcomesKaiser Permanente Southern California

Shaw KM, Handler J, Wall HK, Kanter MH. Improving Blood Pressure Control in a Large Multiethnic California Population Through Changes in Health Care Delivery, 2004–2012. Prev Chronic Dis 2014;11:140173. DOI:  http://dx.doi.org/10.5888/pcd11.140173

“Across all ages, races, and sexes, hypertension control has exceeded 80%.”

85.0% BP control

87.9% BP control

81.4% BP control

86.6% BP control85.0% BP control

Why Protocol Implementation as an HHS 2015 Priority Action?

• Strong evidence base for impact• Potential to reach millions of people• Feasible to implement in 12-24 months• Ability to track impact on an existing measure• Starter set of key resources already available

Protocols as a Floor

How  Can a Protocol Help?Move 10MMore People with Hypertension into the Safe Zone

• Expands the care team that can assist in achieving control 

• Standardizes the content and delivery of lifestyle modification advice 

• Lends clarity, efficiency, and cost‐effectiveness to selection of meds

• Specifies intervals and processes for patient follow up 

How Can a Protocol Help?Move 10M More People with Hypertension into the Safe Zone

• Outlines process for management of patients resistant to treatment

• Raises patient and team “radar” about hypertension

• Reduces variation in clinical practice and ensures evidence‐based care for all patients with hypertension

Hypertension

DetectCommunities Equipped 

and Empowered +

Clinical settings using EHR‐based algorithms

Prevalence estimator

Connect Public Health‐Healthcare 

collaborations

Exchange of home BP readings  and clinical 

advice 

Community Health Worker and Home Health Agents

ControlProtocol‐driven Care

Self‐measured BP monitoring

Policies and practices to improve adherence

Smoking

DetectCommunities Equipped and 

Empowered +

Clinical settings using EHR‐based algorithms

Prevalence estimator

Connect Public Health‐Healthcare 

collaborations: E‐Referral to QUIT lines

Exchange of progress in quitting and additional 

support 

Community Health Worker and Home Health Agents

ControlProtocol‐driven Care

Smoke‐free Space Policies

Policies and practices to improve adherence

Identification and spread of Champions’ practices

Lipid Disorders

DetectCommunities Equipped and 

Empowered +

Clinical settings using EHR‐based algorithms

Prevalence estimator

Connect Public Health‐Healthcare 

collaborations: E‐Referral 

Exchange of progress and additional support 

Community Health Worker and Home Health Agents

ControlProtocol‐driven Care

Elimination of Artificial  Trans‐fat Consumption

Policies and practices to improve adherence

Identification and spread of Champions’ practices

• What is working in cholesterol management?• What is missing?• Who’s on the Design Team to fill key gaps?• Who are the Implementers?• How quickly can we act?

Hypertension CholesterolQuestions for You

Join Us

Subscribe—and Contribute to-- the E-Update

Become a Partner

millionhearts.hhs.gov

Be One in a Million Hearts®

Million Hearts® Resources• Turning Point for Impact (Mid-Course Review) • Hypertension Treatment Protocols • Hypertension Action Steps for Clinicians• Hypertension Action Steps for Employers • Hypertension Control Champions • Self-Measured Blood Pressure Monitoring Guides • Spanish language website• 100 Congregations for Million Hearts• Million Hearts Healthy Eating & Lifestyle Resource Center• Million Hearts® Grand Rounds• Million Hearts® E-update• Visit www.millionhearts.hhs.gov to find more resources

Protocol Resources

• http://millionhearts.hhs.gov/resources/protocols.html• Evidence-based protocols examples:

– U.S. Department of Veterans Affairs– Kaiser Permanente– Institute for Clinical Systems Improvement– NYC Health and Hospitals Corporation

• Customizable template • Key protocol components • Implementation guidance