Hypertension Best Practices: Health Literacy and Outreach Plan

1. Hypertension Best Practice Session 5Health Literacy and Outreach Plan

2. Hypertension Best Practice Elements BP measurement: include 2 BP readings if 1st is high Timely follow up: monthly visits until BP controlled Treatment algorithm: low-cost, once-daily meds Communication: building trusting relationships Outreach: using a registry

3. Learning Objectives Review process for obtaining a second blood pressure reading Review process for timely follow-up Develop a plan for outreach using HTN registry Understand the importance of health literacy as it relates to communicating with patients

4. Data Review

5. Uncontrolled blood pressure by month

6. TwoBPreadings when first elevated

7. Two BP readings when first elevated • What is the current process? • How is it working? • Develop a goal for repeat blood pressure readings. • What action(s) will it take to achieve this goal?

8. Timely follow-up data

9. Timely follow-up process • What are some of the barriers to scheduling one-month follow-ups? • What are some ways to increase the number of patients who get a one-month follow-up visit scheduled?

10. Outreach

11. Outreach for uncontrolled BP patients • Discuss a process for conducting outreach to patients with elevated blood pressure. • What will the process look like? • Who will reach out to the patient? • How often will you reach out? • What method will you use to perform an outreach? • How will you measure the effectiveness of the outreach?

12. Outreach (continued) Use hypertension registry to identify target population Example target population and outreach frequency: Adult patients seen by clinic in past two years with last BP ≥ 140/90 and no follow-up scheduled in next 35 days. Frequency of outreach = every 6 months

13. Sampleprocessforoutreach

14. Example outreach message Our records show that your last blood pressure was high (≥140/90mmHg). As you know, high blood pressure can lead to headaches, heart attack, kidney damage, and/or stroke. Please call us at XXX-XXXX to schedule a NURSE blood pressure check in the next 30 days. Let’s work together to protect your health.

15. Outreach next steps What process will work in your clinic? Who will do the outreach?

16. Observation feedback Complete staff observation using an observation checklist and provide feedback

17. Communication

18. Communication homework Pair up Discuss what went well when practicing and what was challenging Share what you might do differently or continue doing

19. Communication strategiesfrom session No. 4 I – Introduce yourself, attend to comfort D – Describe what’s next (including wait time) E – Elicit patient concerns A – Articulate/express empathy L – Leave in a positive way

20. Communication strategiesfrom session No. 4 • What do you think is the cause of this problem? • What course do you expect it to take? • How serious is it? • How does it affect your body and your mind? • What do you most fear about this condition? • What do you most fear about the treatment? (Kleinman et al., 2006)

21. Communication strategiesfrom session No. 4 Focus on patient’s agenda. Draw out the story. “OK”; head-nodding; listen to 3-5 sentences uninterrupted; opportunity to express patient concerns; ask probing questions; tell about yourself. Demonstrate understanding.Respond empathically; show caring; show familiarity with medical or social history. Provide detailed explanation.What is happening and why; present options to patients. Complete the patient’s agenda. Deliver what was promised or negotiate until later. (Table 1 Tallman et al., 2007)

22. Health literacy Click here for a short video on health literacy.

23. Communication: health literacy video Video highlights: • Patients who speak well may not always read well • People sometimes feel ashamed if they are not able to read • It is important to explain diagnoses in simple language • It is important to assess medication adherence and give explicit medication instructions

24. Communication: Health Literacy What strategies1 can be used to improve communication? Teach-back method Use of open ended questions, such as how people take meds Explicit instructions on medications and purpose (e.g. Q12 hours on prescriptions instead of BID; for high blood pressure) Limit to 3-5 key points Use of pillboxes and color charts and pictures Make all handouts applicable for low-literacy patients 1Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN, Harden E, Tant E, Wallace I, Viswanathan M. Health Literacy. Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality. March 2011.

25. Skills Practice Using drawings and/or simple words, describe the following to a patient: Hypertension diagnosis A low-salt diet

26. Implicit bias Refers to attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner They are activated involuntarily and without an individual’s awareness or intentional control. They cause us to have feelings and attitudes about other people based on characteristics such as race, ethnicity, age, and appearance. Source: http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/ Accessed 3-22-17.

27. Implicit bias assignment Take one of the Unconscious Biases Tests on the following website: In the box titled PROJECT IMPLICIT SOCIAL ATTITUDES, click “GO!” to continue as a guest without logging in. At bottom of next page, click “I wish to proceed.” Take one or two of the tests [e.g. skin-toned IAT, implicit associations test] Write a few sentences about your reaction to this test

28. Next Steps Review Repeat BP Timely follow-up Communication: implicit biases homework Practice champion to review monthly data

29. Disclaimer Use of these slides alone will not improve blood pressure control within your practice. Blood pressure control will be achieved through active quality improvement efforts in conjunction with these slides. Practice coach consultation is available to assist you in improving outcomes.

30. Acknowledgements This work was made possible with funding from: The Mt. Sinai Healthcare Foundation Centers for Disease Control and Prevention Special thanks to: Better Health Partnership participating clinics. Health Improvement Partnership-Cuyahoga (HIP-Cuyahoga)

31. Contact Info For questions about the online toolkit or assistance with implementation, please contact our coaching team: info@betterhealthpartnership.org.

32. Thank you!