As is the case across the U.S., with 1 out of every 3 American adults having high blood pressure, hypertension continues to plague an ever-increasing number of patients at Stolz and Hahn Family Medicine. Dr. Hahn and his team understand the importance of hypertension management and set out to enhance their efforts to make blood pressure control their goal. “We recognized this would require a team effort by all staff members,” said Dr. Hahn.
Staff Buy-In
Laura Jennings, PA; Dr. Larry Hahn; and Carley Goldman, PA.
Realigning staff assignments in order to improve coordinated care for patients with hypertension required full staff “buy-in” to achieve a maximum effort. “We held office meetings to discuss strategies and compliance, and also to outline the expectations for each care team member so that everyone knew exactly what was expected of them,” explained Dr. Hahn. While staff buy-in was initially a challenge, the weekly meetings served to pull the team together in a united effort to help improve the health of their patients. “We made sure to let each staff member know how much we appreciated their hard work and participation in this work,” said Dr. Hahn.
Challenges
Dr. Hahn’s patients face multifactorial challenges in regard to blood pressure management, including medication adherence, high medication costs, following up at requested intervals, dietary compliance with salt consumption and weight reduction, as well as overcoming the social stigma associated with taking medications.
Improving Hypertension Control: How They Did It
Two years ago, the practice signed up to participate in the Improving Hypertension and Diabetes Control and Prevention initiative, led by Quality Insights Practice Transformation Specialist Suzy LoPolito, to support their efforts. “We relied heavily on the Hypertension Practice Module from Quality Insights to help us modify our current workflows around hypertension. It also gave us access to helpful educational resources for both our care team and patients,” said Dr. Hahn.
New processes were implemented to review each patient record, including medication compliance, prior to each encounter so that the clinicians could spend more time discussing each patient’s needs and compliance issues. This ensured that all involved parties, including the patient, were on the same page in a coordinated effort to achieve blood pressure control. In addition, the care team began offering patients support literature and reviewed the information on a regular basis. The resources focus on topics such as the importance of taking medications as prescribed, self-monitoring of blood pressure and steps patients can take to reduce their risk of developing cardiovascular disease.
Technology has also helped Stolz and Hahn Family Medicine achieve a hypertension control rate over 80% for the past two years. “Our care team runs a hypertension control rate report under the ‘Quality’ tab in our electronic health record to identify outliers on a regular basis,” shared Heather Foster, MA. “Our hypertension control rate is also tracked quarterly with Quality Insights as well as various payor dashboards and quality reports. We also routinely run a patient medical compliance report.”
Leadership and Learning
In her role with Quality Insights, Suzy LoPolito has been supporting the practice’s hypertension control efforts for the past two years. “Dr. Hahn is a stand-out among his peers. He is a gifted and dedicated doctor who leads his team in providing the best possible care to patients, many of whom suffer from comorbidities and chronic conditions,” said Ms. LoPolito. “Special attention is also made to patient engagement and adopting a team-based Patient-Centered Medical Home (PCMH) model.”
Ms. LoPolito also gives kudos to Heather Foster and the entire team for their positive attitudes, eagerness to learn and openness to incorporate new strategies. “I assisted Heather in using their EHR’s reporting functions to track the rate progress over time for patients diagnosed with hypertension, and to then use this data to address gaps in care in a timely way,” said Ms. LoPolito.
Leveraging Technology and Quality Improvement Programs
Stolz and Hahn Family Medicine has implemented a blood pressure control game plan that works and encourages other physician practices to do the same. “Population management is here to stay and requires both provider and care team education to learn how to maximally utilize the capabilities of your EHR to enhance the care we give to our patients,” said Dr. Hahn. “Engagement in programs like the Quality Insights Hypertension and Diabetes Improvement Program and various payor incentive quality programs allows a practice to elevate the quality of care you can offer your patients while also allowing the practice to thrive financially.”
Learn more about 2019 Million Hearts® Hypertension Control Champions.
Learn more about Stoltz & Hahn Medical Associates.
About the Practice
Larry S. Hahn of Stolz and Hahn Family Medicine and Pinnacle Physicians Group, located in greater Philadelphia, enlists a full team approach to achieve optimal blood pressure control with all of his patients. Dr. Hahn is a solo practitioner whose care team consists of two physician assistants, two staff members dedicated to population management, five nurses, one office manager and five front desk staff.
This family care-based practice patient population consists primarily of adults ranging from middle age through geriatric. The practice is an active member of the Innovative Wellness Alliance (IWA) and the Community Care Collaborative (CCC) accountable care organizations associated with the Holy Redeemer and Doylestown Health Systems.
