Success Story: Wisconsin Chronic Care Team Works to Manage Chronic Conditions

River Falls Medical Clinic, River Falls, Wisconsin (2013)

In previous rounds of the Hypertension Control Challenge, Million Hearts® established a benchmark of 70% hypertension control for applicants’ adult populations. This 2013 success story reflects the earlier benchmark.

Many patients in River Falls Medical Clinic’s (RFMC’s) population in western Wisconsin struggle with coexisting chronic conditions, such as high blood pressure, diabetes, and cardiovascular disease. To improve its hypertension control rate by nearly 6 percentage points during a 15-month period, RFMC and its sister clinics in Ellsworth and Spring Valley used standing orders, care coordination, and health information technology (IT). These improvements meant an additional 539 RFMC patients achieved blood pressure control, reducing their risk for heart attack and stroke.

What They Did

Used team-based care models

RFMC physicians used standing orders that allow medical assistants to provide more independent care. For example, they could order lab work, refer patients to a dietician, and request follow-up visits for patients with uncontrolled high blood pressure. The physicians, medical assistants, and other clinicians worked hand-in-hand with RFMC’s care coordinators to keep patients on track toward controlling high blood pressure, also called hypertension. The care coordinators reviewed electronic health records (EHRs) regularly to see whether control goals were met. The coordinators met regularly with the health care teams to review patient records, identified areas for improvement, and helped clinicians make changes. The nurse care coordinator titrated (measured and adjusted) patient medications based on protocols developed by the group.

Fast Facts About River Falls Medical Clinic Patient Population in 2013
  • 50,784 patients in western Wisconsin are served
  • 18% have high blood pressure
  • 3% belong to a racial or ethnic minority
  • 10% are eligible for Medicaid
River Falls Medical Clinic

“It is exciting to see our process work and know that a patient has received the care they need. We all feel positive about making a difference in someone’s life.”
—Mary Boles, clinical support staff manager and quality manager

Implemented consistent, strategic use of EHRs

RFMC’s original EHR system did not have the tool it needed to track blood pressure and other chronic conditions, so RFMC hired an IT programmer to assist in adding health tracking functions. Afterward, RFMC had a dedicated Chronic Disease Database and reminder system that captured health data such as blood pressure and generated reminders for clinicians. Alongside this digital tool, RFMC used “analog” technology, such as magnets on exam room doors, that remind clinicians to recheck blood pressure if a patient had an elevated reading. Patients whose readings remained elevated after a second measurement were scheduled for a free blood pressure check within 2 weeks.

What They Accomplished

Employing these strategies helped RFMC improve its hypertension control rate from 79.3% in April 2012 to 85.2% in July 2013. As a result, in 2013, 7,788 out of 9,141 patients with high blood pressure had their condition under control.

Advice for Others

For other medical centers focusing on reducing high blood pressure, RFMC recommends

  • Being open to changing the process for managing high blood pressure if elements are not working for members of the health care team or the patient. Finding the right process may take time.
  • Helping all team members understand their roles in controlling high blood pressure so they feel empowered and like part of the process. Sharing data from the EHR system helps team members see the difference they are making.
  • Making clear that EHRs do not negate the need for critical thinking on the part of staff. Give staff the information and resources they need to use provided tools in the context of broader recommendations and guidelines.

RFMC and its sister clinics—Spring Valley Medical Clinic and 2012 Million Hearts® Hypertension Control Champion Ellsworth Medical Clinic—continue to apply lessons learned in each unique setting across each location, especially building integrated team approaches to treat chronic disease. The goal is to continue to be “champions” across all of the clinics.

Learn More

Barriers and Challenges

RFMC initially faced some challenges with staff using consistent procedures for taking blood pressure readings and had no protocol for titrating patients’ medications. RFMC reduced these barriers and improved consistency by checking in regularly with clinicians and offering additional training.

Page last reviewed: May 5, 2020