Focus Area: Individual Patient Supports

Change concepts to change ideas to tools and resources.Individual patient supports are ways that practices can leverage all care steps to better manage hypertension (HTN) for individual patients. These supports span the patient care spectrum, including pre-visit patient outreach, check-in opportunities, interactions during the visit, checkout, and after-visit reinforcement.

Note: Change concepts are general notions that are useful in the development of more specific ideas for changes that lead to improvement. Change ideas are actionable ideas for changing a process. Each change idea lists evidence- or practice-based tools and resources that can be adapted or adopted in a health care setting to improve HTN control.

Individual Patient Supports: Change Concepts

Change Idea:
Use an online patient portal or other approaches so that patients can access tools, information, and practice staff outside face-to-face encounters to address home BP readings and other needs

Tools & Resources:

  • Office of the National Coordinator for Health Information and Technology & National Learning Consortium. What is a patient portal?

Change Idea:
Ensure that the self-management support provided to patients is helpful in their daily routine (e.g., when making food and lifestyle choices)

Tools & Resources:

Prepare Patients and Care Team Beforehand for Effective HTN Management During Office Visits (e.g., via pre-visit patient outreach and team huddles)

Change Idea:
Contact patients to confirm upcoming appointments; instruct them to bring medications, a medication list, and home BP readings; tell them to take medications as instructed on the day of the visit; if possible, instruct them on submitting home BP readings periodically via apps/portal

Tools & Resources:


Change Idea:
Use a flowchart or dashboard with care gaps highlighted to support team huddles

Tools & Resources:


Change Idea:
Design workflows and use tools to ensure that indicated orders/actions occur during the visit

Tools & Resources:

Use Each Patient Visit Phase to Optimize HTN Management: Intake (e.g., check-in, waiting, rooming)

Change Idea:
Provide patients with educational materials to help them understand HTN and its implications

Tools & Resources:


Change Idea:
Provide patients with tools to support their visit agenda and goal setting

Tools & Resources:


Change Idea:
Measure, document, and repeat BP correctly as indicated; flag abnormal readings

Tools & Resources:


Change Idea:
Reconcile medications the patient is actually taking with the record’s medication list

Tools & Resources:

Use Each Patient Visit Phase to Optimize HTN Management: Provider Encounter (e.g., documentation, ordering, patient education/engagement)

Change Idea:
Use documentation templates to help capture key data, such as patient treatment goals and barriers to adherence

Tools & Resources:


Change Idea:
Use order sets (e.g., with prompts for med titration; increase compliance via prescribing from patient insurance formulary, using once daily/fixed dose combinations when possible) and standing orders to support evidence-based and individualized care

Tools & Resources:


Change Idea:
Assess individual risk and counsel using motivational interviewing techniques; agree on a shared action plan

Tools & Resources:


Change Idea:
Support BP self-monitoring: Advise on choosing device/cuff size, check device for accuracy, train patient on use, and provide BP logs (electronic/paper/portal)

Tools & Resources:


Change Idea:
On the patient portal, provide educational materials to support a low sodium diet and exercise and links to community resources or support groups

Tools & Resources:


Change Idea:
Support medication adherence by providing clear written and verbal instructions and encouraging patients to use medication reminders

Tools & Resources:

Use Each Patient Visit Phase to Optimize HTN Management: Encounter Closing (e.g., checkout)

Change Idea:
Provide patients with a written self-management plan, visit summary, and follow-up guidance at the end of each visit

Tools & Resources:

Follow-Up to Monitor and Reinforce HTN Management Plans (i.e., after visits)

Change Idea:
Assign staff responsibility for managing refill requests by refill protocol

Tools & Resources:


Change Idea:
Implement frequent follow-ups (e.g., e-mail, phone calls, text messages) with patients to make sure they are continuing their medication

Tools & Resources:

  • No tools in the HCCP at this time

Change Idea:
Set up an automated telephone system for patient monitoring and counseling

Tools & Resources:

  • No tools in the HCCP at this time

* Source: American Medical Group Foundation’s Measure Up/Pressure Down® 2013 Provider Toolkit.


Additional Focus Areas

Learn more about the other HCCP focus areas:

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