Jarris, Paul E. MD, MBA; Moffatt, Sharon G. RN, BSN, MS; Romero, Elizabeth Walker MS; Sellers, Katie DrPH, CPH
The US Department of Health and Human Services launched Million Hearts in September 2011 with the goal of preventing 1 million heart attacks and strokes over 5 years. Million Hearts combines prevention and control by empowering Americans to make healthy choices, such as preventing tobacco use and reducing sodium and trans-fat consumption, and improving care with a focus on the ABCs (use of aspirin by high-risk patients, blood pressure control, cholesterol management, and smoking cessation). As Centers for Disease Control and Prevention (CDC) Director Thomas Frieden notes, “High blood pressure contributes to more than 1,000 deaths every day.”1 The total estimated annual cost (direct and indirect) of hypertension is estimated to be approximately $70 billion.2 CDC's total annual budget is less than $7 billion.3
ASTHO joined Million Hearts in support of this nationwide priority attention to cardiovascular disease. Our initial emphasis was 2-pronged. First, we engaged with other national partners, such as CDC, Centers for Medicare & Medicaid Services, US Department of Health and Human Services, the National Forum for Heart Disease & Stroke Prevention, the American Heart Association, and the National Association of County & City Health Officials, to bring them together with state health leadership to identify key recommendations for the role of state health agencies in supporting Million Hearts. Second, we conducted case studies on states leading work to reduce cardiovascular disease. By September 2013, ASTHO had, in partnership with the CDC, taken on an ambitious effort to convene a 10-state multisector learning collaborative to use 3 approaches to help prevent those million heart attacks and strokes: (1) proven strategies to improve hypertension diagnosis and control; (2) the integration of public health and clinical care; and (3) innovative application of continuous quality improvement techniques to policy and systems change efforts. This learning collaborative is on an aggressive timeline to impact identification and control of hypertension in 10 states, set the stage for continued scaling up in those states, and spread to the rest of the nation.
ASTHO is an experienced convener of multisector learning collaboratives to address critical health issues, such as CDC's Winnable Battles, prescription drug abuse, the United Health Foundation's America's Health Rankings, and infant mortality. What makes the Million Hearts learning collaborative unique is its simultaneous attention to hypertension, integration, and quality improvement. It also requires a deep foray of public health into clinical medicine.
Improving Hypertension Diagnosis and Control
Million Hearts relies on the 4 clinical aims listed earlier as the ABCs. One of the learning collaborative's key challenges is to address the identification of individuals with undiagnosed, uncontrolled hypertension. Approximately 20% of adults with high blood pressure have no diagnosis of the condition.4 Root-cause analysis reveals several reasons why many people with hypertension have no diagnosis of the condition: lack of health care provider contact, human error in blood pressure measurement, and elevated blood pressure measurements in the clinical setting without a diagnosis being made.
This learning collaborative seeks to increase monitoring and reporting of the National Quality Forum's measure 18: “The percentage of patients 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90) during the measurement year.” Much of the collaborative's work will involve integrating and using existing data systems. There are a multitude of data sources—paper-based records, electronic health records, health registries, insurance claims data, pharmacy data, public health population-based surveys, and health care surveys. The challenge is to integrate these data across state and local systems and for public health and clinical care to use what is available today to drive action. We cannot wait for the perfect health information technology system to evolve.
In the case studies conducted by ASTHO and during site visits with the 10 states in the learning collaborative, health departments, health care providers, and payers discussed their data, workflow, and interventions in their separate worlds. The case studies and state visits highlight how critical systems that connect data among clinical providers, insurers, and public health departments are. Data that remain within one sector or interventions that involve only one part of the system are much less useful and powerful than system-spanning data or interventions. Often, clinics and practices told us that they didn't know when a patient was treated for hypertension in an emergency department or urgent care setting. The case studies and site visits also showed inconsistent practices in the diagnosis and treatment of hypertension. CDC, the American Heart Association, and others have sample protocols for practices to use as they attempt to standardize the way they diagnose and treat hypertension. In our site visits, practices acknowledged that some doctors would diagnose and treat patients with borderline hypertension and then bring them back for medicine reconciliation within 1 week, while another provider in the practice would not bring them back for several months. Creating a workflow that not only acknowledges treatment but also connects the patient to community resources is critical for systematic care and highlights the role of public health in both team-based care and linkages to resources and support.
For the majority of the time, people with hypertension manage their care outside of the clinical setting. This requires both knowledge and self-management skills. One of the ways states are testing improvement in hypertension control is through efforts such as Stanford University's Chronic Disease Self-Management Program. This program empowers patients by providing information about techniques to manage the frustration, fatigue, pain, and isolation that can accompany chronic disease; appropriate physical exercise; appropriate use of medications; communications with family, friends, and health care professionals; nutrition; decision making; and evaluating new treatment options.5
Integrating Public Health and Clinical Care
The 2012 Institute of Medicine report, “Primary Care and Public Health: Exploring Integration to Improve Population Health,”6 identifies cardiovascular disease as one of the priority areas for opportunities of integration between public health and clinical care. Million Hearts was launched with a 2-part goal—preventing and controlling hypertension—which requires participation by both public health and clinical medicine. ASTHO's Million Hearts learning collaborative takes this one step further by requiring each state team to include the following multisector representatives: state and local health agency leads; public and private health insurers; experts in health information technology; regional clinical partners such as a health system, hospital service area, or accountable care organization; health care providers or community-level practitioners; performance improvement managers; and individuals with health equity expertise. Some of these representatives have been easy to pull into state teams, whereas others have required more effort.
But that effort is setting the stage for powerful partnerships. For example, in the learning collaborative, state and local public health representatives are working with clinical providers and insurers to identify current health data and develop data feedback loops to provide clinicians with detailed, timely information on individuals in their practice with undiagnosed hypertension, lack of medication adherence, and missed follow-up appointments. Working with clinicians, public health is identifying critical barriers for individuals in their control of hypertension and then working with community partners to bridge the gap and provide resources for support.
Collaboration with payers, as another example, requires some cross-cultural and translational skills, as those in the fields of public health and insurance often have different perspectives and languages. But insurance representatives have powerful incentives and data that can influence provider behavior like nothing else. In one state the health agency is working with insurers to use claims and pharmacy data to identify hypertensive patients who are not being actively treated and are not filling their prescriptions. Doctors are then notified so they can contact the patients and engage them in care. This work requires public health practitioners to stretch into areas of health systems change rather than program implementation. The learning collaborative format allows states to support each other as they push the boundaries of traditional practice.
The 2012 Institute of Medicine report mentioned earlier depicted integration as a continuum, with isolation at one end and merger at the other. They identified several degrees of integration: isolation, mutual awareness, cooperation, collaboration, partnership, and merger. Most agree that public health and clinical medicine should work together in a way that falls somewhere between the 2 ends of the spectrum. The states in this learning collaborative are pushing the relationships in their communities toward the more collaborative side of the diagram, learning what they can accomplish together, and increasing both public health and clinical care's understanding of the unique assets each possess that can be leveraged for more effective individual and population health improvements. Public health and these multisector entities have been operating in isolation for a long time, and there is trial and error ahead of us before we find the optimal level of integration with each type of partner.
The prevention of a million heart attacks and strokes is going to require major change in how public health and clinical care systems work together, in public health systems, payment systems, health care delivery, and even microsystems (small-practice processes). This 10-state Million Hearts learning collaborative provides a unique laboratory to identify, develop, and implement public health–clinical care integration strategies to combat one of the leading causes of death in the United States. ASTHO convenes a multisectoral Primary Care and Public Health Collaborative of over 50 leading public health and clinical organizations that is leveraging the expertise and leadership of representatives from primary care, academia, insurance, foundations, and public health to implement integrated efforts that improve population health and lower health cost. The Million Hearts learning collaborative is implementing such integrated efforts with a specific focus on preventing heart disease and stroke.
Implementing Continuous Quality Improvement
Continuous quality improvement techniques have traditionally been applied to processes. Originally, they were used for manufacturing processes such as reducing scraps and rework for the defense industry during World War II; later, they were successfully adapted to improve clinical processes such as diagnosis and management of cardiovascular disease and public health processes such as rapid detection of health problems and environmental health hazards to protect the community.
Participants in the learning collaborative are pushing the limits of quality improvement to adapt these techniques for policy change interventions such as adopting administrative rules for reimbursement of community health workers. One state is seeking a way to reimburse community health workers, including pharmacists, for service. This state is rapidly testing clinical protocols to engage community health workers and pharmacists with small protocol and workflow tests. Data are being used from multiple payer partners to help these teams identify the information needed to create a registry of patients needing further treatment. This may take 3 or 4 test cycles in a 1- to 2-month period. On the basis of this information, another set of tests will then address how the handoff to a community health worker may support linkages and what resources in the community can help patients in controlling their hypertension.
These cycles are happening rapidly to ensure that multiple stakeholders see their role, contribute to the solutions, help redirect the process if a test does not show change, and ultimately champion long-term sustainable spread. One state learned through a quality improvement process that their registry needed much more active management. That state is now using hospital community benefit dollars to support a registry manager who actively mines the registry so the information can be used for proactive patient outreach.
This learning collaborative is truly about learning, for everyone involved. This is pioneering work, which will use metrics to demonstrate outcomes in the short 10 months of the learning collaborative. But it is not just a 10-month project: It will create a foundation of health systems change to go further into creating scalable, sustainable multisector systems to increase its impact and facilitate public health agencies' collaboration with other sectors on other critical health issues. Federal, state, and local public health is working together as an aligned public health enterprise to work collaboratively with health care and insurance system partners. No one sector or level of government can tackle this alone.
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