Michigan Million Hearts Two-Year Summary: Saginaw County, 2016

Introduction: In year 2 of our Million Hearts work, we expanded our efforts to a new community, with a focus on revising protocol based on evidence-based and best practices, and improving processes for data collection and evaluation.

Methods: AIM Statement: Improve level of control within the undiagnosed and diagnosed hypertension population by 5% within Saginaw County.

We also established quality improvement processes using Plan-Do-Study-Act cycles that were used in Year one, to improve identification of undiagnosed patients, improve treatment and follow-up of diagnosed patients, and to increase reporting of NQF 0018 (measurement of patients 18-85 years of age with a diagnosis of HTN and whose blood pressure was controlled).

Once patients were identified as uncontrolled or undiagnosed the clinics used patient flows/algorithms to determine the next step in the patient care, such as making the appropriate referral, in this collaborative it was to a to  Diabetes Prevention Program (DPP), a Community Health Worker, or a Nurse Care Manager.

The target population for the Saginaw County Learning Collaborative was persons aged 18-85, who are undiagnosed and had 2 or more blood pressure readings equal to/greater than 140/90; individuals with a diagnoses of hypertension, and the last blood pressure reading being equal to/greater than 140/90. Baseline data was pulled, and on-going tracking of this population was monitored at each clinic.

The total population of the 5 clinics identified by Health Delivery Inc. (HDI), and St. Mary’s of Michigan was 13,145 adults. Within this population we identified 2,195 patients who were diagnosed with hypertension but uncontrolled and 643 patients who had 2 or more high blood pressure readings but were not diagnosed.

Results: As a result of our interventions, 2,026 (92%) of these patients who were diagnosed with HTN have been referred to our interventions, and 607 (94%) of the undiagnosed patients were referred to services which include appointment reminders sent to homes, notes put in patient charts to ensure BP is discussed, and/or referral to a care management, and/or DPP. 

Follow up: 1,182 (58%) of these patients who were diagnosed with hypertension received follow up, and 51% (n=310) of the undiagnosed patients also received follow up. Referral and follow-up numbers continued to increase as the clinics continue to implement this work.

Discussion: Through the learning collaborative we had the ability to collect and respond to data as it pertains to hypertensive patients in addition to longitudinally tracking the impact of our interventions. We have implemented processes to pull names of clients who have blood pressures that are equal to or above 140/90 on a monthly basis has improved our process, new clients and eliminating the clients who are now in the controlled range.

Much of the success of this project can be contributed to the partnerships that were formed prior to implementation, because of these partnerships we have increased networking opportunities for future work. This work also had an impact on existing partnerships, and strengthened working relationships. The partnerships were key to improve blood pressure screening, diagnosis, treatment, and control among high-risk populations impacted by health disparities. Health Delivery Inc. and St. Mary’s continue the Million Hearts efforts in Saginaw County, without the assistance of MDHHS. The health system is sustaining its efforts revise and implement of hypertension management protocol throughout the other clinic sites.

Next Steps: Although the collaborative have come to an end, the Michigan Department of Health and Human Services, is working hard to further develop a Michigan Million Hearts network where those invested in reducing and preventing heart attacks and strokes can share and promote evidence-based practices, facilitate learning across sectors and communities, and foster collaboration and coordination across the state. We believe the value of the Network is in learning from each other, and sharing the work that is being done across Michigan The Heart Disease and Stroke Prevention Unit will provide a free, accessible flow of information through a Network platform which will allow for concrete sharing of evidence-based clinical practices, how to utilize data, and foster opportunities for community resources and clinical practices to link. Members will be able to provide insider tips about available toolkits, share their Michigan stories, and seek out and find additional opportunities. The blood pressure focus of Michigan’s Million Hearts work will help clinicians improve hypertension diagnosis, reduce blood pressure of those with hypertension, and work across systems for coordinated care and consistent data exchange.

Conclusion: Through these initiatives, we have collectively expanded our efforts in blood pressure screening, diagnosis and treatment to increase hypertension control across the participating health systems. We have expanded our knowledge and understanding of the importance of utilizing health information technology, identifying the undiagnosed and higher risk patients, as well as placing additional emphasis on identifying, diagnosing and treating the diagnosed population. Though the development of a Michigan Million Hearts Network, we will share data algorithms for increasing the identification of adults with undiagnosed hypertension, and support the revisions of clinic protocols based on evidence-based or best practices that can be implemented in a variety of primary care settings. We will improve clinic workflows to increase the implementation of the team-based approach in hypertension control. We will align projects with the identified State Innovation Model (SIM) Community Health Innovation Regions (CHIRS) in Jackson County; Muskegon County; Genesee County; Northern Region; Washtenaw County and Livingston County. HDI and St. Mary’s will expand the Million Hearts initiative to the remaining clinics in additional counties across Michigan. We will continue the Million Hearts work by integrating the strategies into many future initiatives through the sharing of evidence based protocols, clinic work flow diagrams, and sharing of successes and lessons learned in collecting data.