Table 3 Features of Project ReD CHiP’s interventions

Goal

• Improve accuracy and reliability of blood pressure measurement and reduce clinical uncertainty

• Add RDs and PharmDs to primary care teams to deliver culturally-sensitive patient education, promote self-management behaviors and improve access and team functioning

• Incorporate best practices in physician education by assessing PCP needs, delivering an interactive program to provide practical communications skills training and providing performance data feedback on blood pressure control among patients stratified by race/ethnicity

Participants and clinics

• Medical assistants and providers

• Eligible patients (SBP ≥ 140 and/or DBP ≥ 90 mmHg) attending the clinic; providers and clinic staff in referral process

• Providers

• All six participating JHCP clinics

• All six participating JHCP clinics; staggered roll out between 2012-2015

• All six participating JHCP clinics; staggered roll out between 2012-2015

Rationale

Errors resulting from suboptimal blood pressure measurements can influence treatment decisions [14–16]

• Two systematic reviews of quality improvement strategies for hypertension management show team change interventions including assignment of some responsibilities to health professional other than provider result in largest blood pressure reductions [17, 18]

• Participatory decision making style is associated with higher patient satisfaction, continuity of care, improved self-care behaviors and greater adherence to medications [11, 19–22]

• Standardizing and improving reliability of blood pressure measurements may improve PCP confidence in measures and reduce clinical inertia for treatment

• Audit and feedback approaches have been associated with improved quality metrics

• Provides standardized measurement for other two interventions

Level of intervention

Patient

• Providing posters in check-in and exam areas that demonstrate appropriate positioning and give reasons for new process

• Participating in three care management sessions, totaling two hours

• Promoting patient engagement indirectly by enhancing providers’ patient-centered communication and participatory decision-making skills

• Intervening on lifestyle: exercise, weight loss, DASH diet, medication adherence

Provider and staff

• Educating providers and medical assistants about proper blood pressure measurement through didactic and skills practice

• Referring eligible patients to care management team

• Providing audit and feedback via race-stratified hypertension dashboard and web based video training targeting communication skills that promote patient adherence

• Receiving reimbursements for panel review of eligible hypertension patients

Clinic

• Introducing tools to facilitate adherence to recommended techniques (e.g., Omron HEM-907XL)

• Embedding RDs and PharmDs in clinics as part of the provider support team

• Building hypertension dashboard on existing JHCP provider dashboard

• Redesigning patient intake protocols (proper patient positioning and multitasking during Omron use)

• Contracting with JHCP IT team to develop and refine hypertension dashboard

Stakeholder input

Patients/ community

• Suggested posters in exam rooms to explain new process

• Recommended specific educational materials and suggested changes to language, layout and images

• Provided suggestions to make patient stories more realistic for communication skills program

Medical assistants

• Focus groups informed intervention development and implementation plan

• Focus groups informed intervention development and implementation plan

N/A

• Identified and trained Master Trainers and Super-Users at each clinic to support adoption of devices

• Disseminated time-saving techniques developed by medical assistants to all sites

Provider

• Focus groups informed intervention development and implementation plan

• Focus groups informed intervention development and implementation plan

• Focus groups informed intervention development and implementation plan

• Directed interviews to assess organizational culture

• Directed interviews to assess organizational culture

• Directed interviews to assess organizational culture

• Identified JHCP provider champion

• Identified JHCP provider champion

• Identified JHCP provider champion

JHCP leadership

• Directed interviews to assess organizational culture

• Directed interviews to assess organizational culture

• Directed interviews to assess organizational culture

Johns Hopkins Health Care (JHHC)

N/A

• Modified existing care manager job description for RDs • Subcontract with JHHC to hire and fund study RDs

N/A