Hypertension: Case Study: A Practice Process Part 2 of 2
Lisa Tobias, Practice Administrator
Swanee Kooistra, RN, Hybrid Care Manager
Presenter Introductions
• Lisa Tobias, Practice Administrator, Internal Medicine of West Michigan
• Swanee Kooistra, RN, Hybrid Care Manager, Internal Medicine of West Michigan
Objectives
• Present a practice process that impacts patients with uncontrolled Hypertension
• Demonstrate the impact care management activities may have on patients with Hypertension through the presentation of a case study
• Provide an opportunity to discuss focused, team-based approaches to impacting patients with Hypertension
Review of data revealed that some of the patients with high blood pressure readings at office visits did not have this addressed during the visit
Determined a need for a process to address blood pressure for every patient if it was measured to be above recommended limits during any office visit
Identification of Need
Develop a protocol all patients will have a blood pressure recheck if outside of
parameters during an office visit Parameters established
> 140/90 Non Diabetic > 140/80 Diabetic
Develop Standing Orders Formalize Rooming Procedure Guidelines
Medical Assistant will measure blood pressure at every visit
Implementation Steps
An identified High Blood Pressure is flagged for the Provider or Medical Assistant to repeat at the end of visit. Circle the reading Sticky note Flag
The Provider will indicate on the encounter form that a Blood Pressure follow up visit is required for the patients who have a second High Blood Pressure reading.
Procedure:
The patient will schedule the next planned visit with the provider and a Walk‐in Blood Pressure check by a Medical Assistant as indicated on encounter form.
These appointments are often scheduled at different time intervals. Two weeks for Walk‐in Blood Pressure check by the MA One month for planned visit with the provider
Procedure (continued):
Patient will be given the Blood Pressure Appointment Reminder Form before leaving the clinic.
The Walk‐in Blood Pressure check, done by the Medical Assistant, can be done when convenient for the patient any time in those two weeks and is not billed to insurance or the patient.
Procedure (continued)
Follow up Blood Pressure check with the Medical Assistant is documented and signed off by a Provider while the patient is in the office for the walk‐in appointment.
The Medical Assistant discusses the provider’s plan/orders with patient and reminds the patient of upcoming appointment with the Provider.
Procedure (continued):
Age: 71 Race/gender: White female Medical history:
DM type 2 HTN Obesity(BMI‐39) Hypothyroidism
Referral: 3/5/2013 from her PCP for elevated A1c
Case Study: Identification/Referral/Screening
Initial visit: Vital signs: Weight: 218 pounds A1C: 7.9% BP: 168/86
Medications: Hydralazine, Diltazem, Tenormin, Diovan/HCT, Levothyroxine, Aspirin, Multivitamin, Calcium and Metformin.
Case Study: Enrollment
Psychosocial: Lives alone. Mother lives in same neighborhood(patient
assists her mother as needed). 3 daughters‐ one with MS. 4 sisters and 1 brother. Youngest sister recently died after
having a stroke.
Retired. Volunteers 2 days a week for hospice care (sitter) Level of function: Alert, oriented X 3, Able to read, able to
communicate verbally. Appears anxious at times.
Case Study: Enrollment (continued)
Barriers identified Initial reluctance of patient to bring medication to the
office Anxiety over her elevated A1c reading Anxiety related to her elevated blood pressure readings
(secondary to recent death of younger sister)
Case Study: Assessment
Plan of Care: 1) Educate patient how her lifestyle affects her diabetes
and blood pressure. 2) Have patient monitor blood sugars and blood pressure
at home. (Have patient bring in equipment to observe correct placement and size of cuff and compare readings with office equipment to verify accuracy).
3) Follow‐up call weekly with care manager then every 2 weeks until controlled blood sugar and blood pressure readings.
Case Study: Plan of Care
4) Take medication correctly and in a safe manner. 5) Follow office protocol of office blood pressure checks
every 2 weeks or more often per provider's request. (MA continued to complete BP checks as well. These results are communicated to the CM by the MA during the visit).
6) Patient to bring medications and blood sugar and blood pressure log to each appointment.
7) Patient to know what to do if has signs of MI or CVA.
Case Study: Plan of Care (continued)
1) Controlled DM: A1c to less than or equal to 7%, decrease her risks of CV disease, neuropathies, renal complications. Patient to have the knowledge & tools to self manage her diabetes.
2) Controlled HTN : To prevent CV diseases: CVA, MI, CAD, PVD, etc. ADA guidelines: 130/80.
Evidence based: MQIC guidelines ADA
Case Study: Clinical Goals
1)Stop putting all her medications together in a candy jar.
2)Buy and use a medication tray. (A home care referral was discussed but deemed not appropriate because the patient is not home bound).
Case Study: Self‐management Goals
Nursing Interventions and education: Review chart: labs, provider notes, vital signs, medication lists,
outside consult notes. Review patients own self monitoring notes: blood pressure
readings and blood sugars. Provide education on lifestyle modifications
Food: discussed with patient her current foods, schedule, and knowledge of appropriate foods for diabetes and hypertension.
Exercise: discussed with patient her current routine for exercise. Medication: Reviewed her "lists", knowledge of what the medications
are used for, how and when she takes them and affordability.
Case Study: Management
Provide education on lifestyle modifications (continued) Self Monitoring :
Blood pressure cuff at home (automatic). Blood sugars‐best time to check blood sugars.
Review with provider care management plan for the patient.
Review with patient : provider recommendations, case manager's role in her care, her role in managing her chronic conditions.
Case Study: Management (continued)
Documentation Care manager: Initial assessment, F/U phone calls, F/U visits,
blood pressure visits (walk ins done by medical assistants.), provider visit notes and patient's own logs.
Handouts: ADA‐Manage High Blood Pressure. Living with Diabetes(ACP publication)‐ includes section of
pictures and “tips about salt”. Heart Attack symptoms. Stroke warning signs.
Case Study: Management (continued)
A1c is now 6.4% Lifestyle changes: exercising 5 days a week, up to 30
minutes. Food: decreased her carbohydrate intake. Blood pressure still high at 180/80, but diastolic down. Continues to come in for blood pressure checks. Continues to forget to bring medications to office visits. Bought a medication tray!!!
Case Study: Outcomes
Policy: High Blood Pressure at time of visit Process Reminder card /blood pressure checks HEALTH TIPS/education Living with Diabetes(ACP publication)‐ includes section of pictures and “tips about salt”
Resources
American College of Physicians HEALTH TiPS are a free tool meant to improve the clinician‐
patient encounter by facilitating a focus on the key information needed to manage each health condition.
HEALTH TiPS are two‐sided 4”x6” sheets which help patients to ask their physician important questions related to their health conditions.
HEALTH TiPS are written at or below a fifth grade reading level and enable patients with limited health literacy to have more effective interactions with their physicians.
http://www.acponline.org/patients_families/products/health_tips/
HEALTH TiPS
Document can be found athttp://www.acponline.org/patients_families/products/health_tips/hyp_en.pdf
Hypertension: Health Tips
Living with Diabetes Available for purchase fromhttps://www.acponline.org/ebizatpro/ProductsandServices/EverydayGuides/EverydayGuidesDetail/tabid/242/Default.aspx?ProductId=20530
American College of Physicians
Additional Resources
• American Heart Association ▫ What is High Blood Pressure▫ Stroke warning signs ▫ Heart attack warning signs
• MQIC guidelines for Hypertension• Hypertension Clinical Pathway• CardioSmart.org• Provider Toolkit
American Heart Association
• What is High Blood Pressure? (Patient brochure)http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_300310.pdf
American Heart Association
• What Are the Warning Signs of Stroke? (Patient brochure)
http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_300317.pdf
American Heart Association
• What Are the Warning Signs of Heart Attack?
(Patient brochure)http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_300319.pdf
Hypertension mqic Guidelines
http://www.mqic.org/pdf/mqic_medical_management_of_adults_with_hypertension_cpg.pdf
CardioSmart
• American College of Cardiology has a personal “dashboard” on www.CardioSmart.org
• Patients can track their blood pressure, weight, activity, manage medications, etc.
• It is a very user friendly, interactive tool – and it’s free!
Provider Toolkit
Step by step guide for implementing focused,team-based approach to Hypertension management. http://www.measureuppressuredown.com/HCProf/toolkit.pdf
Questions
• We will now take questions from participants regarding the implementation of this practice process.
Webinar: July 10,2013• Title: Care managing Obesity in Adults.▫ Presenters: ▫ Maureen E. Irwin, RD, PA-C, care manager ,
Administrative Network, Inc., Oakland Southfield Physicians, PC.
▫ Dawn Rodman, MS, CWHC, CPT, Michigan Health and Wellness 4X4 and MI Healthier Tomorrow, Michigan Department of Community Health
▫ Annemarie Hodges, MA, Public Health Consultant, Michigan Department of Community Health-Arthritis Program.