Lynn Community Health Center

Lynn Community Health Center Recognized as a Million Hearts Hypertension Control Champion Using DRVS and Improved Workflows to Achieve Blood Pressure Control for 80% of Patients

Lynn Community Health Center is a non-profit, multicultural, community health center located in Lynn, Massachusetts. Recognized as the first user of Azara DRVS, Lynn is a leader in developing new initiatives that result in high-impact, low-cost health care, and innovators when it comes to using data to improve the lives of their patients. At the health center, physicians, NPS and PAs lead teams of health professionals that can address most any ambulatory health need or chronic condition. They are joined by highly qualified mental health therapists, dentists, optometrists, and pharmacists, and other specialists in creating a patient-centered medical home. A significant portion of their patient population is those who experience the most significant barriers to care: children and their families, the poor, minorities, non-English speaking, teens, and the frail elderly. Over 90% of the health center’s patients live at or below 200% of the federal poverty level, and over 50% are best served in a language other than English.

A Million Hearts and 3,000 Patients

According to the Centers for Disease Control, nearly 1 in 3 American adults have high blood pressure, a leading cause of heart disease and strokes. Less than half of adults with high blood pressure have their condition under control. Even more alarming, millions of Americans have high blood pressure that is undiagnosed or untreated.

After analyzing UDS hypertension reporting data, Lynn CHC realized their blood pressure control measures were not fairing as well compared to their peer health centers in Massachusetts. They also determined that they had approximately 3,000 patients with hypertension – a significant prevalence within their patient population. Knowing they had access to the right data through their Azara DRVS Population Health Management System, the Lynn CHC team set out to create a performance improvement program that could help lower and control blood pressure,
and ultimately save lives.

Pat Lee, MD, LCHC’s Chief Performance Improvement Officer at the time, began investigating Million Hearts – a national initiative, co-led by the CDC and Centers for Medicare & Medicaid Services aimed to prevent 1 million heart attacks and strokes between 2017 and 2022. Million Hearts recognizes and awards professionals, practices, and systems who have been able to achieve blood pressure control for at least 70% of their adult patients with hypertension. There are no cash prizes. However, the workflow and clinical changes needed to achieve the 70% threshold could also prove to strengthen health center operations and improve patient care for all. 

The Million Hearts application process was not a small feat. It required verifiable high blood pressure control data using control charts from DRVS and a sample of a real patient records from Lynn CHC’s EHR system, Epic. In a nutshell, the application process ensured the patient data health centers were submitting as the baseline was real and accurate.

The Million Hearts data requirements were extensive. Azara DRVS provided what we needed to apply, and then once the project launched, we could track patient visits, measurements, and improvements for the reporting period and beyond.

- Bob Dempkowski, Senior Data Analyst, Lynn Community Health Center

The 12-Month Challenge

Lynn CHC’s application was approved, and before the formal program started, Lynn CHC provided a LEAN Orientation to all staff. The training emphasis was on continuous improvement and respect for people with the focus on blood pressure control.

Steps include:

  • Take accurate blood pressure reading of all patients
  • Re-check blood pressure if elevated
  • Diagnose Hypertension (HTN)
  • Coach lifestyle changes and treat to achieve targets
  • Outreach directly to patients if the patient has not recorded a blood pressure reading in six months

Additionally, the health center standardized on how they took blood pressure readings including proper cuff size selection and the appropriate posturing of patients. Rechecking blood pressure also became a standard practice especially if a patient is nervous or coming in for urgent care.

Lynn CHC included 100 providers in the 12-month Million Hearts initiative, from all of the existing primary care teams with behavioral health represented on each. The teams soon implemented a new workflow that combined communications, technology, and engagement improvements as detailed below.

Technology

  • Updated the registry (DRVS) used to track patient data

  • Created action buttons at the bottom of the registry

  • Performed data analysis to uncover whether the adapted blood pressure workflow was impacted by outside changes or the initiation of the new workflow

  • Developed run charts to view the mean versus the median

  • Used Azara DRVS for the reports and workbench

Communications

  • Created signs and reminders to notify providers to check a patient’s blood pressure

  • Highlighted overdue patient data to alert providers

  • Initiated calls to patients

  • Used outreach lists to contact the YMCA’s for interventions

Engagement

  • Mapped out a patient’s next two to three visits

  • Created group visits and individual appointments to accommodate patients

The above workflow and its components plus a little healthy competition among the five provider teams helped Lynn CHC see increased improvements in hypertension control by 10%.

Azara DRVS plays a significant role in the daily lives of the providers at the health center. All clinical team leaders have DRVS accounts, and they can easily access reports when they need them, use the dashboards to see how they are tracking against goals and download patient details quickly. As early adopters of health information technology, Lynn CHC understands how data can transform their practice.

Results and Recognition

Lynn Community Health Center achieved a target rate of 80 percent and out of 100 Million Heart applicants, were recognized as one of 24 Million Hearts Hypertension Control Champions in 2017, and the only Champion from Massachusetts.

As hoped, the blood pressure control initiative improved the lives of their patients and enabled the team at Lynn to develop a successful workflow that could potentially treat other chronic conditions such as depression and chronic opioid use.

“The hypertension initiative energized our staff,“ said Kiame Mahaniah, MD, Chief Executive Officer “When they could see the accurate blood pressure data first hand and see the improvements in their patients, it motivated everyone to advance how we deliver primary care at Lynn Community Health Center.”

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