Scaling And Spreading The Heart360© Innovation Part 2

Welcome to the Heart 360 Innovation Video Series prepared by the Agency for Healthcare Research and Quality's Health Care Innovations Exchange. These videos are part of Million Hearts, a Department of Health and Human Services national initiative aimed at preventing 1 million heart attacks and strokes over the next five years. This is one of two videos that focus on the Heart360 innovation, a program involving home blood pressure monitoring, that uses the Heart 360 online reporting system developed by the American Heart Association. Dr. David Magid developed and implemented the Heart 360 innovation in Kaiser Permanente Colorado. Dr. Magid is the Director of Research for the Colorado Permanente Medical Group and an Associate Professor of Emergency Medicine and Preventative Medicine at the University of Colorado Health Sciences Center. The Heart 360 Innovation was one of several programs featured in a Million Hearts event in April 2012. The Million Hearts initiative invited prominent health care thought leaders and stakeholders to Washington DC, to inspire creative thinking about scaling and spreading cardiovascular prevention activities throughout the United States. Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality and Dr. Thomas Frieden, Director of the Centers for Disease Control and Prevention, inspired and motivated attendees to achieve the Million Hearts goal. Throughout the day the attendees shared real-world success stories about service delivery innovations shown to improve blood pressure and cholesterol control. Attendees also brainstormed ideas to scale and spread these and other innovative approaches to better heart health. At the meeting, Dr. Magid provided an overview of the Heart 360 program, addressed issues central to scaling, including implementation challenges, and then forecasted the return on investment. A reactor panel of experts representing different stakeholder perspectives then commented on the feasibility of the program's spread. This Reactor Panel included: Nancy Artinian, Associate Dean for Research and Director of the Center for Health Research at Wayne State University, speaking from the perspective of a Cardiovascular Disease Provider and Specialist. MaryAnne Elma, Director of Quality Innovation and Implementation at the American College of Cardiology, commenting from the perspective of a spread agent. Veronica Goff, the Vice President at the National Business Group on Health, commenting from the perspective of a health care purchaser. Bruce Siegel, President and Chief Executive Officer of the National Association of Public Hospitals and Health Systems, speaking from the perspective of a purchaser and potential adopting organization. And Lisa Simpson, the President and Chief Executive Officer of Academy Health, reacting from a policy perspective. Let's begin with a brief overview of this presentation. The Heart360 program offers medication therapy management to patients who record their home blood pressure measurements, 3 to 4 times each week in the American Heart Association's Heart360 system. Pharmacists monitor and review these measurements, modify medication therapy, and consult with the patient on lifestyle changes as needed. The Heart360 program improved blood pressure control for Heart360 participants. Participants were more satisfied with their care when compared to patients not in the program. The program has the potential to save millions of dollars each year. A 10-year forecast demonstrates a savings of 20 million dollars annually. Let's take a look as our innovator and experts talk about scaling and spreading the Heart360 innovation. Part two of this video series will focus on stakeholder interests in the innovation and external environmental factors that affect the spread of the innovation. What's the benefit for each and every stakeholder, what's the benefit for the patients, what's the benefit for the doctor, what's the benefit for the pharmacist, everybody is tuned into that station WIIFM, what's in it for me, and that's just human nature. You're asking someone to change for the status quo that they're comfortable with to some new way of doing things that they're initially not comfortable with, simply because it's new. And there has to be a sense of tapping into that intrinsic motivation, I want to do this because I can see a benefit for myself and for others. And being able to articulate that for various groups is something that we know that good leaders and good spreaders of ideas do. They talk to different audiences in terms that resonate with them. A lot of times with particularly the provider but the patient as well, it is a, to eliminate the feeling of the burden of more work to do, where time spent, more cost, this seamless integration of what's new into what's already being done is vital, and I see that you did that with the pharmacist and then it's part of their usual function to already do the service. So my question is tying all that together, was there any pharmacist feedback? So you have patients satisfaction, I wonder did you have any feedback from the pharmacist about how this went for them and other people like the nurse who did the education, what did the primary doctor think when they got that notice? Did it mean nothing, was it just something that they normally get or on top of things that they always get anyway. I wonder how, what's the value of that there because that to me are the proof points, those are the things that you can articulate for innovation spread into other settings and that's my one question, so what was the feedback from the pharmacist? So first of all, we did survey the pharmacist, and they actually were very happy to be involved. The only thing that they said was the dissatisfier was what I alluded to before which was the fact that they had to kind of use two systems. I mean they were both on their desktop, but they had to kind of flip back between the electronic health record which is where they would document what they were doing and communicate with the physician, and the data on the blood pressures themselves which were stored in a separate system because we couldn't get that data in the electronic health record, and so that was the one thing that they said that they would really, that would really make it easier for them, but they enjoyed being involved and were happy to continue and some of them have said, well, why aren't we doing this? We talked about the patients and the providers were perfectly fine with this. We had not a single complaint the whole time. I will say this, we did do sort of analysis of a efficiency so we have pharmacists who manage patients who have uncontrolled hypertension in an office-based model and we are able to measure sort of prospectively how many patients they are able to take care in their office-based model versus how many they can take care of in a home blood pressure model, and we do know that it's probably close to about three times as many patients can be managed at any given time by a pharmacist in a home blood pressure model than in an office space. And that's probably for a couple of reasons; one is in an office-based model if the patient comes in and their blood pressure is normal where you still need to meet with them. In a home blood pressure monitor, if the blood pressure is normal, you don't need to do anything, the patient knows that and you know that, and also with an office space model, you have a fair number of people who schedule and office visit and then don't show up and you don't have that same kind of problem. So when I see the benefits cast in terms of dollars, that may mean a lot to the CFO, and that's great, but to whom are those benefits accruing and I wonder about the benefits of those on the front line who are actually doing this work. So is it better to think about this perhaps, not only the cost saver maybe, although after three years may not be compelling, depending on who you are, but as something that can improve access, something that can reduce crowding in say the family health center at San Francisco general. Something that can free up beds, that can be used for patients who really need to be in those beds, somebody that can decompress my emergency department and overall just take work out of the system, work we can't afford to support anymore. So I'd be curious to your reactions to that. That's, well, it's interesting because the, I mentioned Kaiser Southern California and the fact that they have a clinical champion there, Joe Handler who is really moving things quickly into implementing it in their system and that's exactly what's driving them so the idea that they have thousands or tens of thousands, I don't know what the number, but some very large number of visits that are purely for hypertension and they've kind of looked at that and said, why do we have these visits? And they said, and mostly it's just check the patient's blood pressure and to sort of reinforce things and they've sort of said, well, these, and so many of those patients, 85% of the patients who come in for those visits have normal blood pressure. And so this is really a waste of a really important resource that we have. We have other people who need to get in for other reasons and we can manage these patients without having them come into the office so that in fact is the drive in Southern California, it's not the lower blood pressure and it's not the higher patient's satisfaction, it's actually freeing up valuable resources that they could use in a better way. I guess then I would maybe suggest that one of the things, you mentioned efficiency, I think we do need to press on that, and productivity as well. That will help I think sell the idea to purchasers knowing that people are actually not spending a half day going to see the doctor for a checkup. So I'm wondering if you guys have thought at all about how this would work in the fee-for-service system and are there some critical things that you can point out, I don't know if it's high touch, I mean you talked a little bit about the cuffs, but are there critical elements that will transfer into other delivery models? Well, I think the thing that I learned was if providers can't get paid, they're probably not going to do it. Now Kaiser being capitated wasn't something that we ever think about. So in a model like ours where getting paid isn't really that important, because we get an upfront fee and then we use those resources, that's not an issue. But right now, as I understand it, most third party payers will not reimburse for this, so it seems like it's almost a non-starter if we can't change that. I really don't think this works in a fee-for-service environment. I think putting on a payment for it is just going to confuse things and, I mean not confuse things but just make things potentially worse. One thing I would challenge to think about instead of using pharmacists, I mean the same kind of model could be in a patient center, medical home, with some kind of global payment or some other, some different payment than fee-for-service, or an ACO using other people. The other thought about the expansion is, and other partnership that I wonder about, is the increasing presence in the marketplace of our large pharmacies, Wal-Mart, Target, Walgreens, and retail clinics and to what extent certainly in conversations with some of the leaders in that market, they're seen as sort of the new wave of primary care providers and being able to leverage them even more, so is that another way to diffuse outside the Kaiser environment because I do think that that's the biggest limitation to spread and diffusion is getting beyond the capitated model and are there other models that might make this work. As you think about, you mentioned ACA earlier and the added burden on primary care providers with this influx of newly eligible patients and mainly childless adults. Have you talked to your Medicaid partners about this for the future, what kind of conversation could be had with Medicaid about making this a covered benefit under the Medicaid program, so. We're going to need a lot more partners, different payers, policymakers, even some non-traditional healthcare providers like Wal-Mart and other places that are setting up these kinds of clinics. Are there ways of partnering with them that cause the spread to happen? We also know that a lot of innovations are first occur in kind of non-traditional setting, they're first done for a group of customers that don't normally get service or on some other way, so it doesn't always start with traditional folks, who are so steep in the status quo that in fact aren't able to make that change. When I look at major health systems in the country and major safety net systems, I think there's more than a realization, there's an acceptance that we're going to have to do less with less. The idea that we're going to keep getting payment levels going up and keep during more patients with more resources, it's over. Now I really do think among the leadership of your organizations that has now sunk in, and has taken decades for that to happen. We're going to have to do less with less, with superior outcomes. For more information on this and other innovations please visit AHRQ's Health Care Innovations Exchange Website at innovations.ahrq.gov. To learn more about the Million Hearts Initiative visit: milionhearts.hhs.gov