Focus Area: Population Health Management

Change concepts to change ideas to 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

Use a Registry to Identify, Track, and Manage Patients with HTN

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:

Use Clinician-Managed Protocols for Medication Adjustments and Lifestyle Recommendations

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

Tools & Resources:

Use Practice Data to Drive Improvement

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 Toolkit.


Additional Focus Areas

Learn more about the other HCCP focus areas:

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