Checking blood pressure

Connecting rheumatology patients to primary care for high blood pressure

Connecting rheumatology patients to primary care for high blood pressure

High blood pressure is the most prevalent cardiovascular risk factor for rheumatology patients, yet blood pressures are not frequently addressed in specialty visits. Dr. Christie Bartels et al. developed the BP Connect Health protocol to address this issue by training medical assistants and nurses to (1) re-check high blood pressures, (2) advise patients about the link betweeen rheumatic and cardiovascular diseases, and (3) connect patients with timely primary care follow-up using electronic health record orders. In an analysis of the intervention, investigators found that the odds of timely primary care follow-up doubled and the media time to follow-up declined by nearly half, from 71 to 38 days. Additionally, the number of rheumatology visits with high blood pressure declined from 17% to 8% in the 2 years after the protocol was implemented, which suggests that the protocol resulted in population-level declines in high blood pressure. A free toolkit with the BP Connect Health protocol and tools to successfully implement it is available on HIPxChange here.

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Implementing a mobile health system to integrate the treatment of addiction into primary care

Implementing a mobile health system to integrate the treatment of addiction into primary care

Dr. Andrew Quanbeck et al. implemented a mobile health (mHealth) system to help treat patients with substance use disorders. The investigators evaluated the effect of the system on patients and clinicians using the RE-AIM framework and found that the system improved care among primary care patients with substance use disorders and that patients using the system supported one another in their recovery. However, among clinicians, use of the technology was less robust than the use by patients, and ongoing funding and lack of availibility of the data in the electronic health record were challenges.

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MyHEART: Development & dissemination of a patient-centered website for young adults with hypertension

MyHEART: Development & dissemination of a patient-centered website for young adults with hypertension

In this article, Dr. Heather Johnson and team discuss the development of the MyHEART website and toolkit for young adults with hypertension. The website and toolkit were implemented successfully with input from community and healthcare stakeholders to provide evidence-based education to a hard-to-reach population.

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A family-centered rounds checklist, family engagement, and patient safety

A family-centered rounds checklist, family engagement, and patient safety

In a recent randomized clinical trial led by Dr. Elizabeth Cox, implementing a checklist during family-centered rounds increased family engagement and the safety of hospitalized children from the perspective of the families. The checklist was developed with input from the hospital staff and families of hospitalized children, and two items were found to significantly increase family engagement: when hospital staff read back orders, families engaged in more decision-making and provided more information, and families were also more engaged when the team talked about goals for discharge. The materials needed to implement the family-centered rounds checklist in are available in a free toolkit here.

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MyHEART: A non-randomized feasibility study of a young adult hypertension intervention

MyHEART: A non-randomized feasibility study of a young adult hypertension intervention

This study led by Dr. Heather Johnson sought to examine the feasibility of the MyHEART program, a telephone-based health coach self-management intervention for young adults with high blood pressure. The study team found MyHEART to be feasible and acceptable to young adults with uncontrolled hypertension. More patients reported blood pressure monitoring after the study, all coach-patient encounters were documented in the EHR for PCP review, and surveys indicate that patients had a positive experience with the intervention.

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Doctor counseling patient

Visit patterns for severe mental illness with implementation of integrated care

Visit patterns for severe mental illness with implementation of integrated care

This retrospective cohort pilot study by Meghan Fondow et al. examined visit patterns for over 1,000 patients with severe mental illness using EHR data from two federally qualified health centers. During the intervention period of a model that integrated behavioral health services with primary care, there was a significant increase in the proportion of visits per month. After the intervention, this rate declined but remained above pre-intervention period.

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C-TraC Nurse on Phone with Patient

Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital

Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital

The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among patients with high-risk conditions discharged to community settings from the hospital. Patients in the C-TraC program experienced one-third fewer rehospitalizations than those in the comparison group and there was an estimated savings of $1,225 per patient. This model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or constrained resources. A toolkit with the C-TraC protocol is available on HIPxChange here.

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