The Wisconsin Nurse - October 2018

Page 16 The Wisconsin Nurse October 2018
Healthy Nurse
BP Connect: Improving follow-up after high blood pressures in specialties
Researchers at the University of Wisconsin created an effective staff protocol
to improve follow-up after high blood pressures (BP) in specialty clinics. The
protocol, called BP Connect, is designed to connect patients with high blood
pressure in a specialty visit back to primary care for timely follow-up. In a recent
study, BP Connect doubled rates of timely follow-up and lowered the number of
rheumatology visits with high blood pressures recorded by 9%.
BP Connect is a staff protocol performed by nurses or medical assistants
during vitals assessment using a series of electronic health record (EHR) alerts
advising staff to Check or re-measure high BPs, Advise with brief counseling,
and Connect using a simple clickable follow-up order. It was created from
an evidence-based primary care hypertension staff protocol, which was
then adapted for use in specialty clinics. The short video here https://vimeo.
com/212653638 demonstrates the protocol.
The protocol was developed because high blood pressure is the most
prevalent and reversible cardiovascular disease risk factor among adults with
chronic conditions, who are often vulnerable to gaps between specialty and
primary care. Increasing preventive services to address hypertension could
prevent more early deaths than any other preventive service, such as lipid
treatment, cancer screening, and pneumococcal or influenza vaccination (Farley
Am J Prev Med, 2010).
It is rare that high blood pressure is addressed in specialty visits. For example,
in rheumatology visits even when a blood pressure of ≥160/100 was taken, blood
pressure was not discussed in two-thirds of the visits; only 1 in 10 received any
advice to follow-up for high blood pressure.
Wisconsin’s Diabetes Prevention Program
Jean Roedl, FNP-BC, ADM-BC
There are more than 84 million people in the United States with prediabetes
but only 11.6% of them have been told by a health professional they have it.
According to the Chronic Disease Prevention Program in Wisconsin 9% of
Wisconsin adults have diabetes and one quarter of them do not know they
have it. What is more alarming is 34% of adults in Wisconsin have prediabetes.
Prediabetes is a condition that leads to Type 2 diabetes and it also raises the
risk for stroke and heart disease. Studies have shown that with a few lifestyles
changes, such as reducing stress, losing 5% to 7% of body weight and adding 20
minutes of physical activity to every day can help people delay or even stop the
development of Type 2 diabetes. This can be a difficult change for people trying to
improve their health.
The Chronic Disease Prevention Program within the Wisconsin Department of
Health Services uses a multidisciplinary approach. The approach parallels with the
Center of Disease Control (CDC) and the National Diabetes Prevention Program
for at risk adults. The National Diabetes Prevention Program (DPP) is a year-long
evidence-based program focusing on long term lifestyle changes of weight loss,
healthier food choices and lowering their risk of developing Type 2 diabetes. The
group support offers one-on-one guidance with trained lifestyle coaches.
Participants make a long- termed commitment to achieve long lasting
behavior changes. The one-year program consists of 16 one-hour weekly
followed by 6 one-hour monthly classes the reemphasize the earlier lessons
and help the participants to stay on track. The participants must fall into the
categories listed to be eligible for participation in Lifestyle program: 1. Must
have had a blood test with in the past year that indicates prediabetes or history
of Gestational diabetes. 2. Overweight adults 18 or older with BMI greater of 24
or greater (Asian Americans: 22 or greater) 3. Screen positive for prediabetes
based on National Diabetes Prevention Program Risk Test. For information go to
DOIHavePrediabetes.org.
Since 2013, the program has trained over 130 lifestyle coaches in Wisconsin
and has been adopted by 12 health systems, three tribal nations, five communitybased
organizations, three major employers and the Wisconsin Department of
Corrections. -Wisconsin Department of Health Services 9/2017. On October
24, 2017, I was invited to be part of a State Engagement meeting was held in
Wisconsin Dells to help create an actionable plan to increase awareness,
screening, testing, referrals, availability of National DPP classes in the state, and
increase both public and private coverage for the National DPP. Key speakers
included Mark Wegner MD, Chronic Disease Medical Advisor-Wisconsin
Department of Health Services, Division of Health; Pat Schumacher MS, RD,
Division of Diabetes Translation-CDC and Prevention, Bo Nemelka, MPH, Leavitt
Partners and Joel Riemer, AMA. There were several speakers that shared success
in Wisconsin from perspective of Health care systems, the insurer, the employer
and a National DPP provider at YMCA.
Nationally, there are more than 1400 CDC-Recognized organizations that
offer the National DPP lifestyle change program to over 100,000 participants.
Several states provide coverage through Medicaid or state employers. Over 60
commercial health plans provide some coverage for the program and Medicare
will start to reimburse for the program April 2018.-National Association for
Chronic Disease Directors. An online National DPP Coverage Toolkit, launched in
2017 by National Association for Chronic Disease Directors and Leavitt Partners
and funded by the CDC can help organizations with offering the program as a
covered benefit. www.NationalDPPCoverageToolkit.org
This may be due, in part, to the perception that specialists do not consider
blood pressure care to be within the purview of their practice. Specialty clinic
visits comprise 49% of United States ambulatory visits, and specialty physicians
outnumber primary care physicians. As such, specialty clinics have the
opportunity to improve cardiovascular care for patients most at risk.
The BP Connect staff protocol was developed at three rheumatology clinics at
a large academic health system. Dr. Bartels and her multidisciplinary team used a
participatory work system redesign to develop the protocol, and held focus group
sessions with medical assistants (MAs) and nurses to (a) assess current processes
and needs, and (b) develop an EHR-supported blood pressure alert and referral
process.
Dr. Bartels’ team then conducted a study on the effectiveness of the BP
Connect Health protocol (Bartels et al. Arthritis Care and Research, 2018) and
found that after implementing the protocol, the odds of patients receiving timely
primary care follow-up for high blood pressures doubled, and the median time
to follow-up declined by nearly half, dropping from 71 to 38 days. Additionally,
rheumatology visits with high blood pressures recorded declined from 17% to
8% over a 2-year period, suggesting that the protocol helped reduce high blood
pressures in this population.
A toolkit that contains the BP Connect protocol and a variety of resources
to enable organizations to implement it effectively is available for free on
HIPxChange.org. The toolkit can be used by health care administrators, clinicians,
and/or researchers who seek to improve follow-up care when high blood
pressure is identified in specialty clinics.
While the original implementation of BP Connect Health was in rheumatology
clinics, it could also be used in other specialty clinics. The program would be
particularly relevant to specialties associated with high cardiovascular disease
risk (e.g., status post-cancer, HIV care, etc.) where high blood pressures are not
addressed routinely (e.g., non- cardiovascular specialty clinics).
In addition to the BP Connect program, Dr. Bartels has developed other
protocols to improve the cardiovascular health of patients in specialty care. Quit
Connect is a specialty protocol to improve referrals to tobacco quit lines, and
materials to implement the protocol are also available for free on HIPxChange.
org. Fit Connect is currently under development and uses an electronic health
record referral system to connect arthritis patients to an evidence-based arthritis
activity program.
More Information and Resources
• https://www.hipxchange.org/BPConnectHealth Contains the BP Connect
protocol and tools to implement it effectively
• Bartels CM, Ramly E, Johnson HM, et al. “Connecting rheumatology
patients to primary care for high blood pressure: specialty clinic protocol
improves follow-up and population blood pressures.” Arthritis Care Res
(doi: 10.1002/acr.23612. [Epub ahead of print]). https://www.ncbi.nlm.nih.gov/
pubmed/29856134
• For more information, contact Dr. Bartels via email at cb4@medicine.wisc.edu
Million Hearts
For the last five years, WNA has partnered
with the Department of Health Services,
Chronic Disease Prevention Unit for a grant that
was awarded to support the efforts to promote
health and prevent and control chronic diseases
and their risk factors. The funding supports the
implementation of evidence and practice-based
interventions for reducing the prevalence of
hypertension in Wisconsin.
Hypertension (high blood pressure) significantly increases the risk of heart
disease and stroke, which account for 1 in every 3 deaths in WI. (Wisconsin
Department of Health Services. Set Your Heart on Health Toolkit. DHS
publication No. P-02154, Madison, WI; 2018.)
Outcomes related to the grant include:
• WNA successfully implemented “The Healthy Nurse” to assist RNs to
ensure interventions to control their own blood pressures and sustain a
journey to individual health.
• WNA facilitated partners to build a culture of Patient Centered Team-
Based care.
• WNA convened an expert panel to discuss Hypertension and a
publication was created to discuss the outcomes.
• WNA hosted a Symposium on Hypertension to discuss strategies for
reducing hypertension in WI.
Currently, the grant has been expanded to obtain information related to
Hyperlipidemia (High Cholesterol). WNA will be sending a survey related to
RN knowledge about cholesterol. Watch for an educational webinar that will
be available on the WNA Website.
You are invited to access the link on the WNA website that has informative
materials related to the grant at https://wisconsinnurses.org/wna-co-leadssymposium-to-address-hypertension-in-wisconsin/