#1Managing Hypertension A Presentation for the Provider Community Developed by: Department of Vermont Health Access (DVHA) Vermont Department of Health (VDH) + Community Partners Vermont Chronic Care Initiative (VCCI) VERMONT DEPARTMENT OF HEALTH healthvermont.gov OneCare Vermont (OCV) Revised 12/23 VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#2What We'll Cover Health inequities that influence hypertension control • Performance measurement and monitoring for hypertension control ● The purpose and core elements of developing a self-monitoring blood pressure program (SMBP) within your practice 2 Prescription for home-use blood pressure monitors and cuffs for patients with cost barriers (examples of completed forms will be provided) • Innovative approaches that local practices are implementing to improve blood pressure control • Locating resources on this topic VERMONT DEPARTMENT OF HEALTH VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#3Learning Objectives Following today's webinar, you will be able to: 1) Identify several health inequities that influence hypertension 3 2) Summarize the key performance measurement strategy for hypertension control 3) Examine opportunities to include a self-monitoring blood pressure program (SMBP) within your practice 4) Use prescription to provide home-use blood pressure monitor + cuff to patients for whom cost is a barrier VERMONT DEPARTMENT OF HEALTH VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#4Hypertension in Vermont Paul Meddaugh, Heart Disease & Diabetes Epidemiologist Vermont Department of Health 4 VERMONT DEPARTMENT OF HEALTH#5Vermont Hypertension Prevalence The Vermont hypertension prevalence has remained statistically similar since 2011. -Vermont United States 29% 30% 30% 30% 30% 27% 27% 25% 26% 25% 26% 25% 2011 2013 2015 2017 2018 2019 2020 Source: Behavior Risk Factor Surveillance System (BRFSS), 2011-2020. 5 VERMONT DEPARTMENT OF HEALTH#6Health Inequities and Hypertension 37% 22% Any 27% Disability LGBTQ+ 30% 24% No Yes No Poor Mental Health 27% 24% Non-LGBTQ+ Sexual Orientation/Gender Identity 25% 6 Hypertension is significantly more likely among adults: With any disability. With poor mental health. Living at a low or middle SES compared to a high SES. Living in a small rural town compared to an urban one. Vermonters of Color White, Non-Hispanic • Race/Ethnicity 33% 27% 21% 27% 30% 24% 22% Source: VT Behavior Risk Factor Surveillance System (BRFSS), 2020. Low Middle High Isolated Small Micropolitan Urban Small Rural Rural Socioeconomic Status (SES) Geographic Isolation VERMONT DEPARTMENT OF HEALTH#7Vermont Hypertension Primary Care Visits The rate of primary care visits for hypertension among insured Vermonters has trended down since 2018. Rate of Primary Care Visits per 1,000 Insured Vermonters 278.6 249.7 259.7 259.5 223.6 7 * 375.0 376.8 350.9 332.5 285.9 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Source: GMCB Vermont Health Care Uniform Reporting and Evaluation System (VHCURES), 2011-2020 - extract 3005 - extracted 10/25/22. *Comparisons 2015 and earlier to post-2015 should be made with caution due to changes in the number of private payers submitting to VHUCRES beginning in 2016. All analyses, conclusions, and recommendations provided here are solely those of the Department of Health and not necessarily those of the GMCB. VERMONT DEPARTMENT OF HEALTH#8Hypertension-Related Mortality The rate of all hypertension-related deaths among Vermonters is significantly higher than hypertension as the primary (principal) cause for death. This indicates that the burden of hypertension is as a contributing factor to disease. Mortality Rate per 100,000 Vermonters 259.8 222.2 226.1 228.6 228.5 205.6 208.6 175.8 190.4 178.8 191.5 20.8 19.6 24.6 25.5 32.9 28.3 29.8 36.2 33.4 41.0 39.2 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Source: VT Vital Statistics, 2010-2020. 8 VERMONT DEPARTMENT OF HEALTH#9Self-Measured Blood Pressure Monitoring Programs (SMBPS) 9 Implementation of SMBPs have increased at VDH partnering health centers from 2020-2022. Blood pressure monitor loaner libraries have increased over time among health centers with an SMBP. 75% 100% 100% 89% 78% 67% 2020* 2021 2022 Proportion of Partnering Health Centers with an SMBP Source: Vermont Health Systems Quality Improvement Assessment (VHSQIA), 2020-2022. *In 2020, fewer (N = 6) health centers were working on heart disease prevention strategies than in subsequent years (N = 8, 2021 and 2022), as a result, this value reflects only those working on heart disease strategies in 2020. VERMONT DEPARTMENT OF HEALTH#10A Closer Look: Vermont 80 Medicaid 69 The blue line shows the percentage of Vermont Medicaid members 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mm Hg) during the previous year. The red dotted line displays the national 50th percentile for Medicaid programs. The blue line is Vermont's actual performance. CBP: Controlling High Blood Pressure (GC-22) 10 Data Source: Healthcare Effectiveness Data & Information Set (HEDIS) - Hybrid Specification starting 2014 61.8% 61.1% 58.6% 56.4% 56 43 59.9% 55.5% 52.6% 52.1% 49.9% 42.6% 30 2016 2017 2018 2019 2020 2021 2022 2014 2016 2018 Current Target Value Current Actual Value Trend 2020 Labels Clearlmpact.com#11HBPM & Measuring Performance 11 Home Blood Pressure Monitoring Now Part of Annual CBP Performance Measure Starting in 2021, the NCQA revised the HEDIS measure on Controlling High Blood Pressure to include remote blood pressure monitoring readings • ➤ This underlines the importance of encouraging the use of home blood pressure monitors and documenting those readings during telehealth visits and other patient transmissions or encounters Remote Blood pressure readings done at home can be captured during a follow-up in- person office visit, telehealth visit, telephone visits, e-visit, or virtual visit. ➤ Patient-reported readings taken with a digital device are acceptable and should be documented in the medical record along with the date. ➤ Providers don't need to see the reading on the digital device; the patient can verbally report it This information, and more, can be found on the Hypertension Provider & Patient Tip Sheet VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#12Project Work: Interventions so far • Our project strategies have revolved around: making automatic blood pressure devices with cuffs more accessible and affordable ● Expanded ICD-10 diagnosis codes (clinical criteria) encouraging patients to join educational workshops that promote the importance of self-monitoring BPs www.MyHealthyVT.org raising awareness among providers about measuring, diagnosing and documenting these BP reading in patient charts ● Developed a Provider/Patient Tip sheet (click here) MY HEALTHY VERMONT HIGH BLOOD PRESSURE MANAGEMENT VERMONT DEPARTMENT OF HEALTH#13Clinical Checklist ✓ Send Progress Note to support diagnosis and need for frequent monitoring (clinical criteria) 13 ✓ Send prescription with diagnosis of XXX, prescription: “automatic BP device with cuff" (and specify if small or extra-large is needed), quantity #1 ✓ Send completed DME form VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#14Clinical Slide - Prescription Example Mock Prescription Prescription should include: 14 14 • Diagnosis with ICD 10 code. • Sig: Automatic blood pressure device with cuff. Include directions. • If larger or small cuff indicated please sure to ensure include in prescription ie, Auto BP cuff with X large cuff. (Avg size cuff 9" to 17" in circumference.) Patient: Jane Doe Address: 444 Main Street, Kalamazoo, VT Phone:444-444-4444 Provider: NPI 333-333-333 Automatic blood pressure device with cuff Dx: Hypertension [include ICD:10] Sig: Take blood pressure daily and record in log Disp: 1 حلا#15Cuff Sizes Cuff Sizes Corresponding to a Patient's Arm Size Arm Arm Bladder Dimension Cuff Size Circumference, Circumference, (width*length), cm* cm cm Small adult 22-26 8.7-10.2 12x22 Adult 27-34 10.6-13.4 16×30 Large adult 35-44 13.8-17.3 16×36 Extra-large adult 45-52 17.7-20.5 16×42 (Thigh Cuff) 15 *Bladder and cuff size may differ by manufacturer. Source: Table 3: Muntner P, Shimbo D, Carey RM, Charleston JB, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73:e35-e66. doi: 10.1161/ HYP.000000000000008. VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#16DEPARTMENT OF VERMONT HEALTH ACCESS VERMONT MEDICAID MEDICAL NECESSITY FORM (MNF), GENERAL (EXAMPLE - ORTHOTICS, PROSTHETICS, MEDICAL SUPPLIES & DURABLE MEDICAL EQUIPMENT All claims for supplies and equipment require a written order. Orders must be signed by a physician, physician assistant, or nurse practitioner. All home health plans of care require a physician signature. Copies of the order must be kept in the patient record by both the ordering provider and Durable Medical Equipment (DME) supplier. It is the responsibility of the ordering provider to complete or review this Medical Necessity Form (MNF) and provide adequate documentation supporting the medical need for the items listed. The ordering provider must provide this documentation either for the Medicaid beneficiary to take to the DME supplier of choice or directly to the DME supplier The DME supplier must be enrolled in Vermont Medicaid. The ordering provider must document a description of the device and/or its HCPCS code. If the ordering provider does not provide the HCPCS code, the DME supplier must provide the HCPCS code for all prior authorizations and on all claims, on this form or on other documentation submitted to the DVHA and DXC. The codes submitted to DVHA and DXC must match the description documented by the ordering provider. All orders must adhere to state and federal rules and regulations. Vermont Medicaid Rules can be found online at http://humanservices.vermont.gov/on-line-rules. DME 16 Section A: (must be completed or reviewed and signed by ordering provider) 1. Beneficiary's name: Jane Doe Medicaid ID#: 123456 2. Diagnoses: 110 Essential (primary) hypertension 3. Place of service: Home Is the beneficiary living in a skilled nursing facility? Yes No Is the request part of a home health plan of care? Yes Description Modifier Medical Necessity of Item No Expected Length of Need (months) # Per Month Code A4670 Automatic blood pressure monitor N/A HTN 99 1 purchase 4. HCPCs The HCPCS code(s) may be provided by the supplying provider when the ordering provider has included a clear description of the required item(s). I CERTIFY THAT THE ITEM(S) PRESCRIBED ABOVE IS(ARE) A MEDICALLY NECESSARY PART OF THE COURSE OF TREATMENT AND NOT FOR CONVENIENCE, COMFORT, OR PRECAUTIONARY PURPOSES 5. Ordering provider's name & address: 6. Ordering provider's signature: 7. Ordering provider's Medicaid provider #: Date signed: Phone#: See back of form for DME information and instructions The ordering provider must document a description of the device and/or its HCPCS code. If the ordering provider does not provide the HCPCS code, the DME supplier must provide the HCPCS code for all prior authorizations and on all claims, on this form or on other documentation submitted to the DVHA and DXC. The codes submitted to DVHA and DXC must match the description documented by the ordering provider. VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#17Core Elements of an SMBP Program Practice • Practice Protocol: Implement a protocol with a defined workflow, patient eligibility, and action steps. Prepare Prepare Team for engagement: identify team members, standardize training, establish buy-in Determine • Determine Clinical support system: Use an existing model, establish a feedback loop, ensure IT components are in place https://millionhearts.hhs.gov/files/MH_SMBP_Clinicians.pdf 17 VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#18Core Elements of a SMBP Program cont. Empower Patients: Explain the process and train patients on the correct technique • Include written guidance and a link or video in the patient portal Establish the easiest and most hassle-free process to get an SMBP unit to patients Tracking method for patients (online / paper/ etc.) Establish a reliable process to get SMBP values back into EMR Work with billing/coding to maximize reimbursement and minimize patient costs https://millionhearts.hhs.gov/files/MH_SMBP_Clinicians.pdf 18 VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#19Affinia Healthcare - SMBP Patient Criteria and Workflow = occurs inside the health center = occurs both inside and outside health center; patient performs SMBP outside of center Initial visit 1-2 weeks Initial visit Stage 1 Uncontrolled HTN, (BP of 130- 159/80-89): Patient is referred for YMCA BSPM lifestyle and patient engagement program Health center care team does a warm hand-off, or electronic referral to an YMCA Healthy Heart Ambassador (HHA), who is embedded in the health center's cardiology clinic Patient is enrolled in BPSM lifestyle and patient engagement program by HHA From HTN Registry Patient attends BPSM classes at health center and local YMCA; YMCA provides home blood pressure monitor to keep 2-4 weeks 16 weeks Patient identified and Says "Yes" 6 weeks From HTN Registry Stage 2 Uncontrolled HTN, (BP of 160+/90+): Patient is referred for SMBP Hypertension Education Program (HEP) and/or cardiology clinic Patient is enrolled in SMBP and health center HEP and trained on SMBP by Chronic Disease staff; home blood pressure monitor provided for patient to keep Patient attends 6- session HEP at health center and patient does SMBP After completion of 6 sessions, pt referred to YMCA BPSM program Cardiology referrals from other providers Patient sees Cardiologist based on referrals; Cardiologist and Internal Medicine providers refer patients to Pharmacist. Pharmacist addresses barriers to blood pressure control and medication adherence Patient has a follow-up visit with pharmacist and referred to YMCA BPSM or health center HEP. https://millionhearts.hhs.gov/files/MH_SMBP_Clinicians.pdf Clinical Flow#20NOTCH: Issuing and Tracking Issuing and Tracking SMBP devices: 20 Complete device loaner agreement, scan copy into patient's chart "SMBP-Loan" (or generate from patient chart and have electronically sign) and give patient a copy Create a ToDo in the patient's chart and assign the user as the clinic's nurse triage account Assign reason as "SMBP" (allows a way to track patients that are participants in SMBP program) Set ToDo date for return date as discussed with the patient (4 weeks) VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#21NOTCH: Data Collection 21 1. Using a smartphone app linked to the SMBP device the patient can send home BP reading to a specified NOTCH email. (These emails are received by care coordination, saved as a pdf in the EHR labeled SMBP pt scanned data" and then routed to the provider. The document can be tracked using a DM/HM report in Medent. BP results are entered into the vital section of patient's chart) 2. Using the patient portal, the patient can enter the home BP readings and send directly to their clinic. Nursing should accept the data and it will automatically be entered as data into the patient's vitals record. 3. Patient can schedule a 28-day BP check with nursing, at time of receiving SMBP device, if no future appointments are scheduled with their provider. Patients are asked to bring BP readings to follow up appointment or drop them off at office in a specified time. These readings are entered into chart. All appointment types can be tracked and extrapolated in a report. 4. Provide a pre-stamped envelope and form to complete to send results back. A document is created in Medent titled "BP readings" which, once created and closed, can be tracked through Medent reporting. VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#22NOTCH: Using EHR to Follow Up EHR Reports: ● ● • Identify participation Differentiate BPs readings in office versus at home 22 Identifying patients with dx of HTN and not seen in office in past 6 months • Identify participants of program who have not been seen or ● provided BP readings Identify patients who are due to return device Current Data: 800 patients have enrolled Over 4880 have been offered (either have home BP device or declined to participate) VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#23community health centers OF BURLINGTON Blood Pressure Cuff Lending Libraries Started at Champlain Islands site due to lack of pharmacies, lack of insurance coverage Expanded to other sites based on interest/need/capacity Currently we have lending libraries at two sites and for two specific populations; those receiving home care and pregnant patients Variation in how programs were implemented across sites; attempting to standardize while keeping implementation barriers low Use of EHR med module to prescribe in-house cuffs Development of organization-wide protocol to guide sites implementing a lending library#24Resource Slide 24 ● Clinical criteria Cuff size resource Gainwell rep link Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association | Hypertension (ahajournals.org) • MyHealthyVT.org • ● Provider & Patient Tip Sheet Self-Measured Blood Pressure Monitoring for Clinicians (Million Hearts) VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS#25Questions? Primary Contacts: Erin Carmichael Director of Quality Management, DVHA, [email protected] • Rebecca O'Reilly, MS, RD Manager, Heart Disease and Diabetes Programs, VDH, [email protected] 25 VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF VERMONT HEALTH ACCESS