The AMA MAP™ Hypertension Program in Action: Insights from Grace Health

Announcer:
You’re listening to Perspectives with the AMA on ReachMD, produced in partnership with the American Medical Association. Here’s your host, Dr. Charles Turck.

Dr. Turck: 
This is Perspectives with the AMA on ReachMD, and I’m Dr. Charles Turck. Joining me to discuss her experience with the AMA MAP™ Hypertension Quality Improvement Program is Dr. Emily Reidenbach, who’s a pharmacist at Grace Health in Michigan. Dr. Reidenbach, welcome to the program.

Dr. Reidenbach:
Thank you for having me.

Dr. Turck: 
Well, to start us off, Dr. Reidenbach, would you give us an overview of how patients with hypertension are managed at Grace Health?

Dr. Reidenbach: 
Yeah. So Grace Health is a federally qualified health center, and we deliver primary care services. And knowing that hypertension affects so many patients in America, especially here in Calhoun County, we decided to take a truly all-hands-on-deck approach to treating hypertension at our clinic. So we realize that primary care providers are very busy, and leveraging the full scope of different fields in our clinic is what would lead to our success.

So we completely revamped our hypertension treatment protocol, and the key was making sure it included several different scopes of practice. So we made sure that within our protocol, we were touching on things that community health workers could do, our MAs needed to do, our nurses needed to do, and our providers were working with the pharmacy through a collaborative practice agreement. We even involved IT and facilities, who helped us with new scheduling templates within our EHR. And they helped us re-set up our exam rooms so that getting an accurate blood pressure would be very simple and easy in-office. So now within our new protocol, providers are still the ones that are identifying patients with uncontrolled hypertension, and they are referring them to pharmacy for blood pressure rechecks. So under a collaborative practice agreement is where the pharmacist is able to adjust the medications with the provider, and this allows for more rapid medication intensification and helps us avoid treatment inertia with hypertension.

Dr. Turck: 
Now when implementing the AMA MAP™ Hypertension Program, how did you leverage the processes your medical center already has in place?

Dr. Reidenbach: 
So prior to pharmacy being involved in the hypertension rechecks, our floor nurses are the ones who really took the lead on this. So we simply use the exact same process that we use with the RNs and just turned it to the pharmacists. So we use the same templates. We use the same schedules. We already had these in place; we simply copied these and then just allowed the pharmacist to do the recheck instead of the nurse. So all documentation was still done in the EHR for easy communication between the pharmacist and provider. The key difference was our collaborative practice agreement.

The collaborative practice agreement was an agreement between our pharmacists and our providers in the clinic, so if a patient was referred to the pharmacy by a provider, the pharmacist could then adjust blood pressure medications without having to ask the doctor to send the prescription first. So it really allows us to intensify that medication during the appointment instead of going back and forth with the provider, which often leads to a 24 to 48-hour delay, where we could really grab patients when they were invested and when they were with us in the appointment and increase those medications as needed.

Dr. Turck: 
And how long ago did you implement this program?

Dr. Reidenbach: 
We started implementing this about 18 months to 2 years ago. It did take us about 4 to 6 months to get the whole program going. And now, I’ve been seeing patients for hypertension rechecks for about 1 year now.

Dr. Turck: 
And since that time, what changes to your approach do you feel have been the most impactful so far?

Dr. Reidenbach: 
Switching to automated blood pressure cuffs really allowed our clinic to be consistent as far as blood pressure readings.  We also added new training and yearly retraining for these automated blood pressure cuffs on things that are pretty simple and easy, like making sure the patient is seated with their back against a chair for 5 minutes before we take a reading, having both feet on the floor, and making sure we’re using the accurate cuff size. All things that should be done but really need to be reiterated year after year to make sure that the entire clinic gets on the same page.

To go along with that, we also implemented a standardized way to record patients’ home blood pressure readings. This allowed us to document these average readings right in the vitals tab instead of just scanning in a piece of paper into the document section that often just gets buried in the EHR and no one really looks at. So changing to this more standardized way really allowed us to use self-monitored home blood pressures for patients to treat hypertension.

Dr. Turck: 
For those just tuning in, you’re listening to Perspectives with the AMA on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. Emily Reidenbach about the implementation and impacts of the AMA MAP™ Hypertension Quality Improvement Program at Grace Health.

So, Dr. Reidenbach, if we continue zeroing in on the impacts of the AMA MAP™ Hypertension Program, how have these protocols changed how you treat patients?

Dr. Reidenbach: 
The biggest change for me was really the timing of pharmacists’ involvement. This was our first clinical program we implemented at Grace Health for pharmacists. Before we implemented this, a pharmacist really wasn’t involved until the dispensing stage, where we might get to counsel a patient at the counter for just a couple of minutes. Or maybe catch some drug interactions while verifying prescriptions and have to reach out to the provider. But for me, I feel the problem at that stage is it’s almost too late. Patients are already tuned out to their care. They’ve already had an appointment with their provider. They don’t want to wait any longer for their medications or, even worse, the medications just sit in the pharmacy and don’t get picked up and often goes unnoticed, especially in a busy dispensing pharmacy.

So adding the pharmacist earlier on in the process has really allowed us to showcase what pharmacists have to offer. I really get to sit down with the patient, talk to them for a solid 15 to 20 minutes, and just focus on their blood pressure for the entire appointment. We address med adherence, do more of a thorough review or a deep dive into their fill history and things like medication compliance, drug interactions, dosing, and administration, and really get to talk to the patient when they’re invested in that care. So working directly with the providers to manage blood pressure instead of being separated into our individual silos has the been the biggest change for me that really just showcases what pharmacists can bring to the table with hypertension management.

Dr. Turck: 
And would you share a few strategies that your care team has taken to increase the use of single-pill combination products for blood pressure management?

Dr. Reidenbach: 
Yeah. So our biggest strategy was education. We shared a lot of information at provider meetings about single-pill combinations. We educated that patients with hypertension often need more than one mechanism of action on board in order to reach their treatment goals. And single-pill combinations are really the products that are going to do this for us and help eliminate the pill burden that patients do have.

We also listened to what the concerns were that our providers had with single-pill combination products. For example, if a patient has an adverse effect, how do we know which product was the contributing factor? Or which class was really causing those problems? And we educated that when you use these, you have two different drug classes on board. You can often reach your treatment goals at lower doses, and these medications at lower doses are very safe and effective with low incidence of adverse effects, so all of our pharmacists, too, worked to identify when single-pill combinations can be used. So for example, if we see a patient on lisinopril and hydrochlorothiazide, if the provider’s agreeable, we can go ahead and change those to the combination product right in the pharmacy. So we do a lot of that as well.

Dr. Turck: 
And as we approach the end of our program, how has the use of single-pill combinations improved treatment adherence for patients?

Dr. Reidenbach: 
Yeah. So bottom line, I think we can all agree that we would rather take one pill instead of two. It’s just a no-brainer. Single-pill combos is often one of the most common recommendations I have when I’m reviewing a patient’s med list. And it’s also one of the first things I hear from patients when they come to me to talk about their medications. I almost always hear, “Why am I on so many medications? I would love to get off of some of these medications.” And single-pill combinations are a great way to do that. And patients are usually thrilled when I tell them we can get two of their medications down into one.

And when we really place patients at the center of their care like that and they know that you’re working with them to make their medication regimen easier, they’re more invested, they feel more empowered, and they’re truly just more likely to take their medications.

Dr. Turck: 
Well, as those comments bring us to the end of today’s program, I want to thank my guest, Dr. Emily Reidenbach, for joining me to share her experience with the AMA MAP™ Hypertension Quality Improvement Program. Dr. Reidenbach, it was wonderful having you on the program.

Dr. Reidenbach: 
Thank you. It was my pleasure to be here.

Announcer:
This was Perspectives with the AMA on ReachMD, produced in partnership with the American Medical Association. To access this and other episodes in this series, visit Perspectives with the AMA on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!