Controlling Hypertension through Team-Based Care

Controlling Hypertension through Team-Based Care


We are Peninsula Community Health Services,
and we are the Million Hearts Hypertension Control Champion. The mission for Peninsula
Community Health Services is to provide quality health care for all of our patients. One of
our big focuses is hypertension, so this award really highlights the efforts that our providers
and all of our staff have been putting in towards providing exceptional care for our patients.
We see a patient for hypertension follow-up. Their blood pressure is maybe 150 over 96, so
I say, well, we need to change some of the medication. So then I’ll say, I would like
to follow up. So usually the other part is that we make sure that patient follows up
and has a schedule. But sometimes something happens, they don’t show up. So then we
have a very small amount of medication, they have 30 pills. So then what happens is for
any of our refill requests, it goes to our pharmacy team. So then, for example, if I’m
treating a patient with Lisinopril, if the patient needs a refill, it goes to our pharmacy
team. So then the pharmacy team looks at this refill request, is able to look at the progress
notes of the primary care provider to see what the plan was, and they see, oh, their
blood pressure was not at goal, they wanted to be seen at two weeks but somehow the patient
was not able to make it. So they catch that, and then they do another scheduled appointment,
so then the patient is able to get in. If we just gave a one year supply of Lisinopril,
we would never ever catch that. We would never have a follow-up to impact a change. So the
patient needs their medication refilled, we prompt them to call their pharmacy to make
sure that we’re getting the request for the right medication and the right dosing and all that,
and that comes in via fax, it comes in to us in a big box. And so electronically, we
get those requests and then review the patient’s chart for if they’re undercontrolled, if they’re
not controlled, if they’re due for labs, if they’re just due to come in for their
every-six-month visit, or whatnot. And then we send a note to the call center if they
need an appointment, or if they need lab work or something, and the call center calls the
patient. So it’s a very integrated system that we have worked out. 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. And I think, with that, it seems to even it out.
If you don’t have somebody…but everybody should have somebody and be checked because
it’s very dangerous when it gets high. It’s very dangerous. And you can get dizzy, you
can fall down, especially as you’re older, and you can, if you’re driving, anything can
happen. So I think it’s just the best thing to do is to keep that in mind and take care of
yourself. If I were advising someone who wanted to set up a system similar to ours, a big
part of it is provider buy-in. We have great support from our medical providers and our medical
director for this whole program, for the process that we play a part in. Our P&T Committee
sets guidelines, which make it very easy to follow, so we don’t have to pick and choose
and feel like we’re necessarily picking on patients or things like that. We have protocols
in place, so I think that would be the most helpful thing is, you know, make sure that
you have support from your providers and protocols in place that are very clear so that everybody
understands the process. That makes it, you know, the simplest flow for the patient care.
And another vital part is our pharmacy team that’s been around for I would say over
eight years, and embedding them as part of the clinical, they’re very much a clinical
pharmacist, they’re just not dispensing medication. They’re looking at the chart
because we’re electronically integrated. They can see what’s going on. And developing
the guidelines for them to help us with controlling hypertension as well as diabetes has been
part of our success. You know, I know I make a difference. There’s something to be said
for, I’ve said this before, but whether it’s one person that I help, or a hundred people
that I help, going home at the end of the day and knowing that I’ve helped
somebody is a great feeling. And it’s great to know that I am making a difference out
there, and that people are living, they’re being healthier, they’re making the changes that
they need to in order to live the healthy lifestyle.