Hypertension Control Champ Wins with Team-Based Care

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Controlling Hypertension through Team-Based Care

Earlier this year, Peninsula Community Health Services (PCHS) – a community-based non-profit organization dedicated to providing affordable, comprehensive health care services to residents of the Kitsap and Olympic Peninsula areas of Washington – was named a 2014 Million Hearts® Hypertension Control Champion. The health care provider was recognized for its innovations in health information technology, patient communication and its health care team approach. PCHS was one of only 30 practices across the United States to be recognized for achieving blood pressure control in at least 70 percent of its patients.

One of PCHS’s first collaborative initiatives with Qualis Health was in 2011. Qualis Health – the Quality Innovation Network-Quality Improvement Organization(QIN-QIO) for Idaho and Washington – served as the Regional Extension Center for Health IT, supporting PCHS in achieving the Centers for Medicare & Medicaid Services’ Meaningful Use goals. Integrating data across the health system helped PCHS better collaborate with clinical pharmacies as they joined forces to control blood pressure through team monitoring of patient visits.

The landscape of the health care delivery system is in a state of constant change,” said Evan Stults, executive director for communications at Qualis Health. Part of this change includes moving to a more team-centric culture.”

To improve patient care, PCHS developed a system integrating its pharmacy with its primary care team. When patients call to request a prescription refill, the pharmacist checks to see whether the patient has seen the doctor lately.

If a pharmacy doesn’t have recent data on a patient, the pharmacist sends a note to the provider’s call center, prompting them to contact the patient and schedule a check-up. 

If we gave patients a one-year supply [of medicine], we would never have follow-up appointments where we could impact a change."

But it isn’t just the patients that are benefiting from the team-based system. PCHS certified medical assistant Joshua Wyatt is finding new joy in his daily work. Whether it’s one person or 100 people that I help, going home at the end of the day and knowing that I’ve helped somebody is a great feeling,” he said.

Another key to PCHS’ success was having clinical leadership that provided buy-in. As PCHS established protocols and developed a new role for clinical pharmacists in care management, the process became clearly and successfully integrated into PCHS’ workflow.

For PCHS patients like Sharon Cromley, the integrated team-based approach means better self-management of her blood pressure and overall health.

I keep track of it at home, and I go in about every six weeks to have my provider read the list I have and check my blood pressure,” said Cromley. Everyone should have somebody [on their care team] and be checked. The best thing to do is to take care of yourself.”