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Other Change Package Pages: Change Package Home; Put Key Foundations in Place for [Target]; Implement Population Management for [Target]; Case Studies
Below are opportunities for improving [Target] related to individual patient interactions, and tools that can help practices leverage these opportunities. For guidance and tools to strengthen foundational practice capabilities (e.g., around evidence-supported [Target] management and patient engagement) see the Foundations page. For guidance and resources on using population management approaches to improve [Target], see the Population Management page. For examples of how practices have systematically improved [Target], see the Case Studies page.
For examples of "optimal states" for each patient interaction step and how a practice achieved significant HTN control improvements by leveraging many of these opportunities, see the "Clinical Decision Support (CDS) Details" accompanying the CHC, Inc. Quality Improvement (QI) Case Study Narrative in the Office of the National Coordinator for Health Information Technology (ONC) Resources for Improving Care with CDS. These CDS/QI Resources also include worksheets to help document and analyze practice workflows for QI projects such as those focused on [Target], and can help practices incorporate tools such as those outlined below into these workflows (note: header items in black text correspond to care flow steps in the worksheets).
Support Patients in [Target] Self-management During their Routine Activities (i.e., not related to any specific visit)
- Use an online patient portal or other approaches so that patients can access tools, information, and practice staff outside face-to-face encounters to address [Target]
- Patient portal overview and implementation guidance (HealthIT.gov/National Learning Consortium) [website]
- Ensure that the self-management support provided to patients is helpful in their daily routine (e.g., when making food and lifestyle choices), keeping in mind that patients spend only a tiny fraction of their time directly interacting with the practice about [Target]
- Key Messages for Health Coaches Working with Patients (WA Dept. of Health, HTN Improvement Tool excerpt) [PDF]
- See also other self-management support tools on this page and the Foundations page
Prepare Patients and Care Team Beforehand for Effective [Target] Management During Office Visits (e.g., via pre-visit patient outreach and team huddles)
- Contact patients to confirm upcoming appointments and instruct them to bring medications, medication list, and home monitoring results (possibly submit periodically via apps/portal); take medications as instructed on day of visit
- "Call Before Visits" (WA Dept. of Health, HTN Improvement Tool excerpt) [PDF]
- [See also tools under 'Use Registry' on Implement Population Management page]
- Use a flowchart or dashboard with care gaps highlighted to support team huddles
- HTN Flow Sheet [can serve as model for automated EHR-version that highlights gaps] (NYC Dept. of Health) [PDF]
- Design workflows and use tools to ensure that indicated orders/actions occur during the visit
- Planned Care Visit Workflow: diabetes sample, can be adapted for HTN control (within IHI Self-management Toolkit) [PDF]
Use Each Patient Visit Phase to Optimize [Target] Management: Intake (e.g., check-in, waiting, rooming)
- Provide patients with educational materials to help them understand [Target] and its implications
- “Know Your Numbers” and “What’s the Big Deal about Controlling My Blood Pressure?” (WA Dept. of Health, PDFs/posters)
- High BP Fact Sheet (CDC) [PDF]
- Provide patient with tools to support their visit agenda and goal setting
- Bubble diagram to select items to focus on during visit (WA Dept. of Health, HTN Improvement Tool excerpt) [PDF]
- Action Plan Form (within IHI Self-management Toolkit) [PDF]
- BP Log, Graph, and Reminder for Next Appointment (NYC Dept. of Health) [PDF]
- Measure, document, and repeat [Target]-related measurement correctly as indicated; flag abnormal readings
- [see tools on Foundations for correct BP measurement technique]
- EHR screenshot showing abnormal BP highlighted (CHC, Inc., from ONC Resources for Improving Care with CDS) [QI Case Study; scroll down to Figure 2]
- Reconcile medications patient is actually taking with the record's medication list
- IHI Medication Reconciliation Form (Baptist Memorial Hospital form [adapt for clinic]) [webpage/PDF]
- EHR Medication Reconciliation Tool (BIDMC) [screenshot]
Use Each Patient Visit Phase to Optimize [Target] Management: Provider Encounter (e.g., documentation, ordering, patient education/engagement)
- Use documentation templates to help capture key data such as patient treatment goals, barriers to adherence, etc.
- BP Documentation template samples (CHC, Inc., from ONC Resources for Improving Care with CDS) [QI Case Study; scroll down to Figures 1, 5]
- Morisky Scale [items can be used in developing documentation template to address adherence] (Mercy Clinics, Inc.) [PDF]*
- Use order sets and standing orders to support evidence based and individualized care; useful features include prompts for med titration to decrease therapeutic inertia, and support for prescribing from patient insurance formulary and using once daily/fixed dose combinations to increase patient medication adherence
- Diabetes standard order set, adapt for HTN (within IHI Self-management Toolkit) [PDF]
- See All Patients Not at Goal or with New HTN Rx within 30 Days [points can inform order set development] (AMGA) [PDF]*
- Standing Order example (Mercy Clinic) [illustrates some items that can be included on order set] [PDF]*
- Asses individual risk and counsel using motivational interviewing techniques; agree on shared action plan
- Support [Target]-related self-monitoring: advise on choosing device, check device for accuracy, train patient on use, provide measurement logs (electronic/paper/portal)
- Provide educational materials to support [lifestyle changes pertinent to Target], and access to community resources/support groups; offer instructions and support for using patient portal
- Support medication adherence by providing clear written and verbal instructions and encouraging patients to use medication reminders
- Medication Adherence Action Kit (NYC Dept. of Health) [PDFs - see Clinical Tools and Patient Ed Materials]
- Online Tool for Patients to Support Medication Adherence (ScriptYourFuture) [website] (medication list wallet cards in English and Spanish can be ordered in bulk for free here)
- Patient Education on Common HTN Drugs (FDA) [PDF]
Use Each Patient Visit Phase to Optimize [Target] Management: Encounter Closing (e.g., checkout)
- Provide patients with a written self-management plan, visit summary, and follow-up guidance at the end of each visit
- 5As Encounter Form on patient self-management for educator (Mercy Clinics, Inc.) [PDF]*
- Provider Clinical Summary Fact Sheet (National Indian Health Board) [PDF]*
- Patient Participation Handouts (flyer for goal setting) – English and Spanish (Sharp Rees-Stealy Medical Group) [PDF]*
- [see also Action Plan Form above under Intake/Provide patient with goal setting tools]
Follow Up to Monitor and Reinforce [Target] Management Plans (i.e., after visits)
- Assign staff responsibility for managing refill requests by refill protocol (see Brief on Condition-specific Protocols on Population Management)
- Article about implementing a protocol for medication refills (AAFP) [web article]
- Refill Policy Example (Trinity Clinic Whitehouse) [PDF]
- Refill Protocol Example (UTMB) [PDF]
- Implement frequent follow-ups (e.g., email, phone calls, text messages) with patients to make sure they are continuing their medication
- Set up an automated telephone system for patient monitoring and counseling
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