In less than four years, a public health center in San Francisco managed to dramatically improve blood-pressure control among its heavily Asian-American patient population. But their success cannot be credited to just one person, as it took a team-based care approach to score the achievement.
Chinatown Public Health Center (CPHC), part of the San Francisco Health Network Primary Care, submitted data to show that it achieved a BP-control rate of greater than 70 percent and as a result earned Gold Status recognition from Target: BP™, a joint initiative between the AMA and American Heart Association (AHA) to improve blood-pressure control.
CPHC improved its blood-pressure control rate from 73 percent to 83 percent.
In 2017, the AMA and AHA acknowledged early adopters of the recognition program by identifying over 300 organizations. And in 2018, nearly 800 organizations have been recognized for their efforts focusing on blood pressure control within the populations they serve.
“Our strategy is mainly that we can’t do it alone. We have to do it all together,” Yee-Bun Benjamin Lui, MD, an internist and medical director of CPHC, said during a presentation about Target: BP best practices.
The health center delivers care to more than 5,300 patients, 97 percent of whom are adults, with 23 percent being seniors.
Each member of the team plays a pivotal role in enhancing continuity and quality of the care provided. Here are the different roles in team-based care for hypertension control at CPHC.
Primary care physicians (PCP). Physicians lead a team of other PCPs, medical assistants, behavioral assistants, nurses and pharmacists, among others. And they focus on developing a strategy for behavior change for the patient.
Medical assistants (MA). Assisting the physicians are the MAs who are trained to repeat blood pressure measurement to make sure they get an accurate reading. The medical assistants have learned through protocols to repeat measurement between three and five minutes if the BP is elevated to get a more representative BP reading and reduce the impact of white-coat effect.
Registered nurses (RN). Algorithms are available to help RNs conduct nurse visits. When creating standing orders, physicians and RNs are very specific about how to titrate the medication, said Dr. Lui. They aim to provide proper education at each nurse visit to fill in some of the gaps between physician visits.
Pharmacists. At CPHC, the pharmacists are available to work with some of the “harder to control patients,” explained Dr. Lui, such as patients with diabetes or chronic kidney disease. Pharmacists play a key role in helping patients between physician visits.
Behaviorist assistants. Focusing on the social determinants of health, behaviorist assistants identify patients who have problems with food security, transportation or housing. Behaviorist assistants address these barriers to better BP control and overall health. They also provide a “warm handoff” so the physicians have support to handle those issues.
Behavioral-health physicians. These physicians work as counselors and help patients deal with common problems such as depression and anxiety. “We feel we have to deal with the entire patient,” said Dr. Lui. “They are unlikely to be successful in behavior change if we do not address the depression and anxiety.”
Front-office staff. The front-office staff works together to perform outreach calls to patients. For example, if a patient has uncontrolled blood pressure, algorithms are in place to connect them to the pharmacists and RNs for repeat visits and phone call follow-ups.
Nutritionists. Individual counseling appointments with a nutritionist are available for patients. Nutritionists are very important in the community arm. “We have to find ways to support them to promote the behavior change outside the walls of the clinic,” said Dr. Lui.
Quality improvement (QI) staff. The QI team provides monthly data feedback and ties their work to individual patients. For example, the 10 percent increase in BP control equaled 170 patients. And “if you control 11 patients’ blood pressure over 10 years’ time, you prevent one stroke,” said Dr. Lui.
“I use that number to extrapolate and say, ‘Hey, you guys just prevented 17 strokes in the work that you’ve done,’” he added. “We are always trying to find ways to not only change patient behavior, but staff as well.”