Using Data To Tackle Undiagnosed Hypertension and Improve Care

NorthShore Health Centers is a primary care organization dedicated to providing high quality, affordable health care to 14,600 people monthly in northwest Indiana. NorthShore's medical teams are committed to constantly innovating and improving the care they provide at their six locations, which is what drew them to EvidenceNOW.

During their participation in EvidenceNOW, the care team at NorthShore's Hammond, Indiana location recognized that despite their best efforts, they may not be identifying all of their patients who are at risk for heart attacks and stroke. They wondered if by examining patient data in different ways, they could flag those patients and intervene before it's too late. In search of new ideas, the care team turned to their EvidenceNOW practice facilitator, Ms. Jennifer Anglin.

Jennifer and the NorthShore team reviewed evidence-based care protocols. She also shared the Million Hearts^® Hiding in Plain Sight model—an approach for identifying people who have undiagnosed high blood pressure. Working with Jennifer to extract and analyze the practice's patient data, NorthShore's Director of Practice Improvements, Ms. Rachel Mullins, was able to identify adults who were not diagnosed with hypertension but who had a high blood pressure reading during their last visit to the clinic. NorthShore's care team then followed up with those patients and invited them to come in for a free blood pressure check.

As a result of this outreach, four patients who came back into the clinic were sent to the emergency room because their blood pressure was dangerously high. Several patients also were diagnosed with hypertension and prescribed medication to control their blood pressure. Other patients whose readings were normal shared that they felt more at ease after getting their blood pressure re-checked.

"It's been great to learn from the different systems we've implemented, and through our data and patient feedback, to see how we've gotten so much better in quality overall," says Ms. Erin Dickinson, Patient Care Manager at NorthShore. "Implementing small changes and watching how they grow—it has a snowball effect where care continues to get better and better."

This story is courtesy of Healthy Hearts in the Heartland, the EvidenceNOW Midwest Cooperative.