Learning collaboratives are a frequently used public health tool to identify strategies for program change that can be replicated in other communities or spread from one community, state, and across the nation1. However, using learning collaboratives for complex health system change requires careful consideration of the organizational support needed to achieve success. The Association of State and Territorial Health Officials (ASTHO) and its national, state, and local partners have funded and provided coordination and technical support for a highly effective learning collaborative focused on health system change aimed at identification of hypertension and increasing hypertension control. This article describes the key organizational capacity necessary for strategic targeted technical assistance to achieve a successful learning collaborative, including leadership, identification of key levers for impact, resources, rapid-cycle change with monthly reporting, expert partners, and the learning collaboratives in-person and virtual meetings.
Since September 2013, ASTHO, with funding from the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Heart Disease and Stroke, has led a 10-state, multisector collaborative that supports the Million Hearts Collaborative aim of preventing 1 million heart attacks and strokes by 2017. This collaborative has focused on creating a learning environment to bring public health, primary care, community resources, quality improvement organizations, and insurers together to address the challenges of identifying and controlling hypertension. In 2013, medical spending to treat hypertension in the United States totaled $42.9 billion,2 yet 1 in 3 adults has high blood pressure and at least 50% do not have their high blood pressure under control.3 Among African Americans, uncontrolled hypertension is also more prevalent and has an earlier onset.4
It is necessary to improve health care delivery and support lifestyle changes at home and in the community to reduce hypertension rates. However, 1 provider, 1 clinic, or 1 community at a time is not enough to stem the urgent need to effectively impact cardiovascular disease. As was noted in the Institute of Medicine report, Primary Care and Public Health Integration, “The integration of primary care and public health could enhance the capacity of both sectors to carry out their respective missions and link with other stakeholders to catalyze a collaborative, intersectoral movement toward improved population health.”5
In fall 2013, the ASTHO Million Hearts Collaborative began rapid-cycle clinical and data system interventions to accelerate improvement in hypertension control. All 10 states are incorporating National Quality Forum 18, approved performance measure for controlling high blood pressure (NQF-18) reporting into clinics, establishing registries to identify undiagnosed and uncontrolled hypertensive patients, adopting clinical protocols for identification and follow-up with hypertensive patients, and building linkages to community resources, including patient self-management.
Participating states report affecting 90 000 patients and estimate a potential reach of 1.5 million patients. In just 9 months, several clinics demonstrated improvement in the percentage of hypertensive patients under control by as much as 12 percentage points. For example, a clinic in New Hampshire showed a trend in improvement in control rates among patients in its hypertension registry from 64% to 73% in 7 months. States in the collaborative are sharing their experiences with other states, demonstrating that collective national, state, and local leadership can have a demonstrable, positive impact on the cardiovascular epidemic.
Identification of Key Levers for Integrating Health Systems
ASTHO and its partners identified a comprehensive approach to inform each state's work. Key aspects of this comprehensive approach included the following: (1) leadership and engagement of critical partners; (2) using multiple data sources to inform action; (3) using standardized protocols in areas such as hypertension management, community screening and referral, and equipment calibration; (4) identification of financing opportunities including private and public payment and federal and state grants; and (5) identification of community and clinical linkages such as team-based care delivery systems, faith-based outreach programs, healthy lifestyle promotions, and skills development for the self-management of chronic disease.
National, State, and Local Leadership
In 9 months, with the leadership of state health officials, national experts, and ASTHO public health experts, the Million Hearts Collaborative identified new approaches to linking clinical and public health systems to improve population health. State health officials set the vision for their states' projects and played a key role in involving unique stakeholders and convening organizations that had limited experience working together on health system transformation. These linkages created key levers of change, including using state health agency data and claims data to target areas of higher need, focusing on payment incentives to reward quality improvement, increasing providers' best practice clinical protocol usage, and expanding community resources. Leadership at the state agency facilitated an internal switch from traditional program implementation to rapid-cycle, systemwide change, engaging both provider and payer partners.
State health official leadership helped leverage siloed funding and found new funding opportunities, which were key to the spread and sustainability of these early successes. For example, several states in the collaborative are applying for the Centers for Medicare & Medicaid Services State Innovation Model grants, which are aimed at improving population health.
Rapid-Cycle Change With Monthly Reporting
Using an adapted version of the Institute of Health Improvement Breakthrough Series Model,6 ASTHO supports states through a rapid systems change testing process, with focus on system change rather than programmatic change. The PDSA (plan-do-study-act) model creates a format for states and partners to work closely to test plans multiple times before taking them to scale. The state teams' rapid-cycle quality improvement approach focused on both macrosystems (at the state policy level) and microsystems (at the clinical and community levels). State health agencies engage partners at the highest decision-making level as required stakeholders, along with regional partners, community and clinical providers, and local public health agencies. As states implement action plans and learn from each other, this rapid-cycle model allows for all levels of the system to test the model for change, study its effects, test again until the process is fully refined, and then support meaningful spread. Each state and its collaborative partners identified issues and solutions and tested these solutions. In the 9-month collaborative, states conducted more than 250 improvement cycles in 1-month periods, generating rapid successes and helping quickly define impediments to progress.
ASTHO leads this work through funding support from the Centers for Disease Control and Prevention to leverage the national focus on Million Hearts Collaborative. It leveraged this funding to support states, national partners, and internal infrastructure for the collaborative. Through a request for proposal (RFP) process, ASTHO selected 10 states for the collaborative and provided up to $140 000 grants for a 10-month period. In addition to funding, states were provided a structured process for developing and measuring goals, engaging stakeholders, and obtaining access to national and federal experts. States used their funds for support of a lead collaborative coordinator, convening local public health staff, community partners, and other new stakeholders, facilitating reviews of health information technology including development of patient registries, and training for evidence-based programs such as the chronic disease self-management program. For national partners, ASTHO committed resources to national public health specialists in health system change and contracts with national partners and experts in hypertension. For ASTHO infrastructure, resources supported ASTHO staff, 3 site visits by ASTHO public health specialists to support each state collaborative, virtual platform technology to engage partners and peer groups, and 2 in-person national meetings.
Site Visits and In-person and Virtual Meetings
Another key component of the organizational support needed for this successful learning collaborative was a detailed plan for each state's strategic targeted technical assistance. Each state preplan was reviewed by ASTHO public health specialists, who identified specific needs for technical assistance. Public health specialists were assigned to each state and conducted at least 2 site visits to meet with state and local collaborative partners to provide an in-depth understanding of the collaborative's expertise and unique needs. ASTHO's public health specialists instructed state teams how to use the rapid-cycle change approach, reviewed their progress, and identified needs for national experts.
ASTHO also drew on a unique organizational strength: its use of technology to provide virtual meetings to connect all 10 states and their partners for real-time information sharing. These virtual meetings go far beyond conference calls: they facilitate visual presentations and simultaneously engage all partners. Critically, virtual meetings also reduced travel expenses, allowing more partners to be involved. ASTHO staged the learning sessions to meet the needs of the stakeholders and leveraged 1 in-person meeting after states had an opportunity to try 1 to 2 PDSA cycles in their state. Once convening in-person and hearing from the other states, they recognized that other states were facing similar barriers or had solved the issue. For instance, one state explained the algorithms it developed to use emergency department discharge data to target hypertensive patients in a county. Three other states asked to learn more to adapt it to their own state. States were able to share challenges and solutions as well as provide motivation and support.
As a public health tool, learning collaboratives promise to be an effective method to address complex health system change and rapidly spread learnings. Yet, to be effective, these collaboratives require careful strategic organizational support that includes leadership of national organization and state health officials' use of rapid-cycle change with monthly progress reporting, engagement of expert national, state, and local partners, and in-person and virtual meetings for the collaborative teams. It is important to understand how to optimally use this tool for impact, rapid change, spread, and sustainability. An organizational structure to support frequent team communication, linkages to national experts, and required reporting/sharing of progress are all critical to a learning collaborative's success.
The ASTHO Million Hearts Collaborative provides a model of health system change through in-depth technical assistance using rapid quality improvement from a variety of stakeholders to identify and control hypertension and spread this knowledge and experience across communities, states, and regions. As a nation, addressing the complex challenges of health system change will take strong strategic technical assistance to support effective collaboratives, as leadership from public health, clinical providers, and communities work together to achieve rapid health system change.