Focus Area: Population Health Management

Change concept, Change idea, Tools and resources.

Population health management tools and approaches can help clinicians proactively monitor and manage hypertension (HTN) practice-wide. This includes clinician-driven treatment protocols and using practice data to drive improvement.

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.

Population Health Management: Change Concepts

Change Idea:
Implement an HTN registry

Tools & Resources:


Change Idea: 
Identify patients with elevated BP yet without an HTN diagnosis; diagnose HTN as appropriate

Tools & Resources:


Change Idea:
Use a defined process for outreach (e.g., via phone, mail, email, text message) to patients with uncontrolled HTN and those otherwise needing follow-up

Tools & Resources:

Change Idea:
Use protocols to cover proactive outreach driven by registry use and respond to patient-submitted home BP readings

Tools & Resources:

Change Idea:
Determine HTN control metrics for the practice

Tools & Resources:


Change Idea:
Regularly provide a dashboard with BP goals, metrics, and performance

Tools & Resources:

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

Additional Focus Areas

Learn more about the other HCCP focus areas:

Page last reviewed: October 25, 2019