EvidenceNOW: Midwest Cooperative

EvidenceNOW: Advancing Heart Health in Primary Care is an initiative of the Agency for Healthcare Research and Quality (AHRQ) to transform health care delivery by building a critical infrastructure to help smaller primary care practices improve the heart health of their patients by applying the latest medical research and tools. EvidenceNOW establishes seven regional cooperatives composed of public and private health partnerships that provide a variety of quality improvement services typically not available to small primary care practices. The goal of this initiative is to ensure that primary care practices have the evidence they need to help their patients adopt the ABCS of cardiovascular disease prevention: Aspirin in high-risk individuals, Blood pressure control, Cholesterol management, and Smoking cessation. The initiative also includes an independent national evaluation designed to determine if and how quality improvement support can accelerate the dissemination and implementation of new evidence in primary care.

Cooperative Name: Healthy Hearts in the Heartland www.healthyheartsintheheartland.org Principal Investigator: Abel N. Kho, M.D., M.S., Northwestern University Cooperative Partners: Northwestern University [(Chicago Regional Extension Service (REC)] Alliance of Chicago Community Health Services American Medical Association Illinois Department of Public Health MetaStar, Inc. (Wisconsin REC) Telligen, Inc. (Illinois Quality Improvement Organization [QIO]) Northern Illinois University (Illinois REC) Northwestern Memorial Physicians Group Purdue University (Indiana REC) University of Chicago Geographic Area: Illinois, Wisconsin, Indiana Project Period: 2015-2018

Region and Population

The cooperative region encompasses southeastern Wisconsin, northeastern Illinois (including Chicago) and northern Indiana, a highly diverse population of more than 16 million people. Cardiovascular risk factors are prevalent: 31.2 percent have high blood pressure, 29.3 percent are considered obese, 38.1 percent have high cholesterol levels, and 20.5 percent are current smokers.¹ In addition, 34 percent of these patients live in areas designated by the Health Resources and Services Administration as Medically Underserved Areas or are part of Medically Underserved Populations and may have limited access to primary care.²

Specific Aims

1. Evaluate the ability of small practices in the region to a) implement point-of-care and population management quality improvement strategies to improve the ABCS of cardiovascular disease prevention, and b) implement performance measurement software to evaluate performance on the ABCS and allow regional benchmarking.
2. Conduct a practice-randomized trial to determine whether point-of-care strategies improve ABCS performance measures compared to baseline, and whether adding locally tailored population management strategies to point-of-care strategies improves performance on the ABCS measures more than point-of-care strategies alone.
3. Deploy an open-source quality measurement platform (popHealth) to establish a regional quality improvement benchmark based on participating practice ABCS measures and to enable longitudinal tracking of electronic clinical quality measures across the region.

Reach

• Goal for Number of Primary Care Professionals Reached: 750-975.
• Goal for Population Reached: 1.13-1.46 million.

Updates on Key Project Components

Support Strategy

The cooperative will help practices improve the quality of care and adoption of the ABCS through individual point-of-care and population management strategies:

• Point-of-care strategies that focus on improving the quality and efficiency of care delivered to individual patients during office visits. These strategies will include educational tools and electronic reminders to enhance aspirin prescription and cholesterol management; education and patient self-management tools to improve blood pressure control; and staff training and electronic reminders to encourage use of the “5As” (Ask, Advise, Assess, Assist, Arrange) for smoking cessation.
• Population management strategies that use systems-based approaches to improve population health. These strategies will include creating lists of patients eligible for aspirin or cholesterol interventions so that practices can conduct direct outreach, developing partnerships with community pharmacists to enhance team-based blood pressure care, and connecting documented smokers to local quit lines and other telephone-based smoking cessation counseling.
• Learning Collaborative. The Learning Collaborative will offer multiple opportunities for practice facilitators and participating practices to engage in shared learning:
  • Monthly training Webinars.
  • Access to national and regional quality improvement experts Monthly site visits by practice facilitators or other content experts.
  • A listserv for information-sharing and problem-solving.
  • Access to quality improvement tools and resources.

Update:

• Practice facilitators have had kick-off meetings with all the practices in the first wave and some of those in the second wave.
• A primary focus of these early meetings is helping practices understand the capabilities of their electronic health records (EHRs) and how to extract measures for reporting and quality improvement purposes.

Evaluation

The cooperative will use a two-arm, cluster randomized comparative effectiveness trial. In this design, care sites are enrolled and then randomly assigned to the intervention in cohorts, with all sites receiving an intervention. Practices will be assigned either to point-of-care strategies alone or point of care plus population management strategies. The cooperative is programming the popHealth tool to extract high-quality data out of practices' EHRs.

Update:

• More than half of the participating sites will be able to connect to the popHealth platform. The cooperative will use other mechanisms for data extraction for the other sites, where EHRs or database accessibility prevent popHealth's connections.

Strategies for Disseminating Study Findings and Lessons Learned

Update:

• The cooperative plans to disseminate study findings via brand-focused materials distributed through partner networks, a Web site, social media outlets, and scientific publications and presentations.

Comment from Principal Investigator

Abel Kho, M.D., M.S.

“Early optimism around recruiting exclusively from small, independent practices has yielded to a more pragmatic approach to recruitment, with expanded eligibility criteria around geography and size. Recruiting for Healthy Hearts in the Heartland challenged us to examine our value proposition and ensure that it resonated with not just providers, but also with all practice staff. Our final months of recruitment have brought increasingly positive responses from both small practices and other systems, all of whom seek the same quality improvement support.”

Spotlight on Recruitment

Recruitment Specifics

• To date, the cooperative has recruited 147 practices and is now engaged in discussions with several practice networks while continuing to recruit small independent practices and community health centers.

Factors that Contributed to Recruitment Success

• Identifying the value proposition for each practice: Actively listening to and observing each practice identified unique needs which could benefit from involvement with the cooperative. A few themes emerged, including interest in assistance with generating data on clinical quality from the EHRs, direct practice facilitation, help with Meaningful Use and other incentive programs, and professional credit for Maintenance of Certification or Continuing Medical Education.
• Thorough preparation: In some instances, practice facilitators and other recruiters had to “cold call” practices. Being knowledgeable about the practice and its needs (e.g., Maintenance of Certification credits) and well-prepared to discuss the benefits of participation in EvidenceNOW greatly increased the success of these calls.
• Access to HealtheRx: A cooperative partner (University of Chicago) has developed the HealtheRx, a “prescription” for connecting patients to health and wellness services in the communities in the greater Chicago area in which they live. Being able to access this database for referrals was an important incentive for practices to join EvidenceNOW.

Challenges to Recruitment and How the Cooperative Responded

• Limits on the number of small practices: The cooperative discovered that the number of small and medium sized independent primary care practices is shrinking; therefore, the cooperative expanded their search parameters and began recruiting slightly larger practices and practices that were part of larger integrated networks. The cooperative found that the larger practices did not have as strong a quality improvement foundation as expected, so this strategy opened up a new source of potential recruits that could benefit from EvidenceNOW.
• Small practices are too busy to participate: The cooperative leveraged the positive experience of earlier recruited practices to promote and encourage other providers to participate. The cooperative paired practice facilitators with additional team members (e.g., informatics staff) on site visits to enable more study activities to take place within a single scheduled practice visit, a streamlined approach that appeals to providers.

¹ Centers for Disease Control and Prevention. SMART: Behavioral Risk Factor Surveillance System City and County Data. 2013. http://apps.nccd.cdc.gov/BRFSS-SMART/index.asp. Accessed May 27, 2016.
² Health Resources and Services Administration. Shortage Designation: Health Professional Shortage Areas and Medically Underserved Areas/Populations. http://www.hrsa.gov/shortage. Accessed May 27, 2016.