December 9, 2019

State Systems to Support Hypertension Identification and Control


This short video illustrates the framework
used by the Association of State and Territorial Health Officials through its Million Hearts State Learning
Collaborative to support states in developing, spreading, and sustaining statewide systems that improve hypertension
identification, management, and control. To learn more about ASTHO’s Million Hearts
efforts, visit our webpage at www.astho.org/Million-Hearts. The
large blue circle represents an entire state. Within this state are many different communities,
represented by the smaller blue circles. These communities are supported by a variety
of regional and state partners across a wide variety of sectors such as healthcare, public health, health
information technology, clinical quality improvement, academia, state government, healthcare payment,
and many others. And all of these communities and partners
work together to improve hypertension identification and control within a broader context that includes many
other initiatives at both the state and national levels to promote chronic disease prevention, healthcare
delivery transformation, and more. Within each state, each community has its
own unique population. Some communities may have many residents with
high blood pressure, others may have fewer. The residents of each of these communities
may face a variety of barriers to controlling their hypertension, including lack of access to primary care or
care coordination services, issues with taking their antihypertension
medications as prescribed, lack of access to stable housing or transportation,
or lack of access to community resources to support healthy lifestyle choices. Let’s look at one of these communities in
more detail. Regardless of the specific circumstances within
this community, in order for it to optimize its ability to systematically identify community members with undiagnosed or uncontrolled
hypertension and connect them with resources to help them bring their blood pressure under control, partners within
the community must work together to create systems of care that span across all settings and include
several key “backbone” features. These include close collaboration between
clinical, public health, and community partners to identify individuals with undiagnosed or uncontrolled hypertension,
gather and share data with other key partners, and refer individuals with undiagnosed or uncontrolled hypertension
to the appropriate resources. Let’s look at each of these “backbone” components
more closely. Clinical and Healthcare partners play several
critical roles. They systematically IDENTIFY individuals with
undiagnosed and/or uncontrolled HTN using clinical data available through electronic medical records or chart
reviews. They establish standardized hypertension clinical
treatment protocols and workflows to ensure all patients with hypertension receive the same quality
care. They REFER patients to community and public
health resources for care coordination or to support self-management. And they TRACK and monitor patients to ensure
they follow through with their referrals and that their treatment plans are actually making a difference in improving
their blood pressure. Local public health agencies also play a critical
role in these community systems. They IDENTIFY individuals with undiagnosed
or uncontrolled HTN using data sources available to them, which may include community-level hot spotting
or prevalence data, data from direct service clinic electronic health records, community blood pressure screenings, and others. They develop standardized blood pressure screening,
referral, and care coordination protocols and workflows, either for their own clinics or for community
partners. They CONVENE partners and stakeholders to
coordinate efforts, leverage community assets, and address challenges. They support and leverage the workforce of
community-based health care professionals, which may include community health workers, public health nurses,
community pharmacists, emergency medical services personnel, and others. And they TRACK and MONITOR individuals to
ensure they follow through with their referrals and are able to access resources that address barriers to
blood pressure self-management. Community-based partners also play many critical
roles. Some of them, such as faith-based organizations
with parish nurse programs, may have data or information that can help identify individuals in the
community with undiagnosed and/or uncontrolled hypertension who are “hidden in plain sight.” Others, such as libraries and barber shops,
may have direct access to community members who may not otherwise be connected to the healthcare system
and can provide opportunities for blood pressure screening and raising awareness. Other community partners may offer resources
and evidence-based programs to support healthy lifestyles, such as the Stanford Chronic Disease Self-Management
Program, the American Heart Association’s Check Change
Control program, or CDC’s WISEWOMAN program. They may also offer services or resources
to help individuals overcome barriers to blood pressure self-management, including antihypertension medication cost
and access, access to healthcare and healthcare coverage,
and access to social services. Or they may have a workforce of community-based
healthcare professionals, such as parish nurses, EMS staff, CHWs, community pharmacists, or care managers, who
can support individuals in monitoring their blood pressure and accessing the services they need. Community partners can also REFER individuals
to clinical care and/or other services as appropriate and help MONITOR them to ensure they follow
through with referrals by sharing data with clinical and public health partners. In order for community-level systems to function
smoothly and effectively, partners must share data and information with each other in a timely
manner to ensure information is getting to the right
person at the right time to inform referral, management, and follow-up. This information exchange is represented by
the purple arrows here and can take many different forms. However, ideally these data exchange systems
are accessible to all key partners, can be used to generate actionable reports
such as patient lists, registries, or hot spotting maps; and are connected to other state- and local data systems
such as EHR platforms or health information exchanges. These community “backbone systems” should
also effectively move individuals between the services and resources these partners
offer. This concept is indicated by the red arrows. This occurs through high-functioning referral
and follow-up protocols and workflows that include roles for clinical, public health, and community
partners. Each community approaches this work with its
own unique combination of strengths, assets, and challenges. However, while each community may be very
unique, it should still work toward establishing the same foundational “backbone” structures
just discussed. Many regional and state-level partners across
a broad range of sectors also play important roles in supporting, spreading, and sustaining “backbone”
systems and best practices to all communities across the state. Some of the most critical partners are discussed
here, but there are many others. The state health agency plays many important
roles, including convening cross-sector partners to identify and align vision for hypertension
management and control at the state level, identifying and securing state resources,
supporting data access and systems, engaging leadership at the state, regional,
and local levels, and much more. ASTHO has developed several resources describing
in more detail opportunities for state health agencies to support statewide
systems to identify and control hypertension. Both public and private insurers play critical
roles in partnering with public health agencies and other state partners to address hypertension. Some of these roles include testing care delivery
and payment models; aligning incentives for health care providers,
patients, pharmacy benefit managers, and other stakeholders; helping establish and monitor quality metrics,
accessing and sharing member data to identify members with undiagnosed or uncontrolled
hypertension, or who are not adhering to their antihypertension
medication regimens; exploring opportunities to grow, train, and
pay for the workforce of community-based health care professionals; supporting population health and chronic disease
prevention programs for members and employers; and much more. Organizations who work on health IT, health
informatics, and clinical quality improvement can: support regional and statewide data systems;
help develop and align clinical quality metrics and other key hypertension improvement measures; train
and support local clinical partners and other stakeholders in adopting a quality
improvement model, and much more. Many, many other stakeholders also play important
roles. Some of these partners include physician networks,
Hospital engagement networks, Non-profit institutes, Universities, State
hospital associations, State AHA chapters, and employers. All partners at the state and local levels
should coordinate and align across a number of key “levers” to advance and sustain broad systems change
over time. ASTHO’s Systems Change Framework, pictured
here, describes these key “levers.” And finally, as described earlier, all of
this work takes place within a broader context that includes many initiatives that support
chronic disease management, healthcare delivery transformation, and more. It’s critical for states to consider how they
can leverage these other opportunities to spread successful strategies and lessons learned to other communities across
their state, as well as inform their work on other chronic conditions and public health
issues. You can learn more about how states in the
ASTHO Million Hearts Learning Collaborative are using this framework to establish systems
to identify and control hypertension by visiting the ASTHO Million Hearts webpage
at www.astho.org/Million-Hearts.

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