Hi Sara,
We use the attached as our guidelines,
Hypertension Improvement and Treat 2 Target Tool Kit.pdf (nychhc.org)ROLES OF CARE TEAM MEMBERS IN T2TPCP
Document Care Plan:
o BP target, agreed upon with patient
o Current medication regimen
o The plan for changing the medication regimen if the BP is not controlled
after 2 weeks despite seemingly good adherence.
o Referral to RN for HTN care / T2T
RN
Have an in-person or phone visit with the patient every 2-4 weeks: Check BP.
Assess adherence
Assess side effects
Address barriers to adherence
Advise patient on adjustment of medication according to the provider's plan
If the BP is not controlled and graduated after about 4 months in T2T, assess
next steps.
RN – PCP Collaboration
PCP directs RN's care with the Care Plan, and supervises care by reviewing
the EMR and discussing the care.
If the Care Plan specifies next steps, the PCP does not see the patient, but
reviews and 'accepts' the care provided in the visit note which appears in the
provider's "Review Queue"
If RN has any concerns, the RN consults with provider, and the patient may
have further evaluation as needed.
If the BP is not controlled and graduated after about 4 months in T2T, assess
next steps.
T2T CRITERIA AND SUCCESSFUL T2T REFERRALSCriteria: A patient qualifies for referral to T2T if there is a diagnosis of HTN and the
most recent BP reading is above target (target is <140/90 for most patients).
Providers decide when / whether to refer to T2T based on an overall clinical
assessment.
Referral Methods:
Direct referral from provider: A patient being seen for a primary care visit
with uncontrolled HTN can be referred to T2T, even if the BP is only mildly
elevated or has been controlled in the recent past.
Outreach is a good alternative referral method, especially for patients who
have not been seen in several months.
For a successful referral, provider needs to:
Explain the RN T2T program to the patient, emphasizing importance and
benefit of RN management
Document target BP in the EMR (usually <140/90)
Document the treatment plan including medication regimen and healthy
lifestyle changes
Document the medication titration plan (if BP not at target after 2 weeks with
seemingly good adherence)
Strategies to increase referrals to T2T:
Ensure adequate T2T capacity (# slots/week)
Train all staff members on T2T – this helps physicians understand and get
more comfortable with T2T and confident about referring patients
Monitor referral rate overall and by provider. For providers with lower T2T
referrals, explore barriers
Remind providers with lower BP control performance that T2T can help
Use T2T flyers to share with patients and providers
Strategies to increase the T2T visit show rate:
Show rate is often lower for T2T visits, in part because the concept is newer
for patients. Consider:
Provider explaining T2T pathway to patient and emphasizing benefits
Warm handoff
Reminder calls (ensure accurate patient contact info, including back-up phone
number)
Ensure patient can contact T2T nurse by phone as needed between visits.
CLOSING OUT PATIENTS AFTER 4 MONTHS IN T2T When T2T is successful, patients will generally graduate with controlled BP in
less than 3 months.
Patients with uncontrolled BP should stay in RN T2T program a maximum of 3
to 4 months
After 3 months, if the patient's BP is not controlled, the RN should have a
discussion with the patient about next steps and also discuss with the
provider; the RN's supervisor can also contribute to the discussion.
After 4 months, nursing supervisors should assist RNs to close out all patients
and refer back to the provider to decide on next steps.
o Exceptions can be made on a case-by-case basis e.g., if the patient only
recently became engaged and is making good progress.
o See CIP section in this document for guidance on cutting a line list
Some possible next steps for patients closed out of T2T and uncontrolled.
Provider can:
o See patient to discuss barriers and identify possible approaches
o Refer to pharmacist to improve medication regimen (e.g., to address
side effects)
o Refer to cardiology
o Refer to Health Home or Health Home at Risk
o Refer to social work
Sandhya Daniel
Assistant Director for Nursing Professional Development
NYC Health & Hospitals
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Sandhya Daniel
Assist Dir of Nursing Education
Harlem Hospital
New York NY
(347)455-1716
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Original Message:
Sent: 01-11-2023 09:26
From: Sara Small
Subject: Nurse Led Population Health Interventions
Hoping someone here has some insight. I manage a hospital-based primary care practice (practicing under the hospital license as an HOD). One of the quality goals for our practice is to have a certain percentage of our patients with hypertension under control (according to HEDIS measures). One of the interventions we have identified is having patients come in for a BP screening visit with an RN (without having seen a provider). We came up with some guidelines as to when the patient could go home and follow up PRN, need to schedule a provider visit to follow up on a high BP, or needed immediate assessment by a provider during the nurse visit according to the nurse's assessment.
This initiative is a population health approach, where we are not waiting for a provider to order a BP check. We are asking the nurses to use their nursing judgement after assessing the patient to see what the next step would be. I believe that this is within the scope of an RN (we are in CT). However, some of the nurses are weary of doing this type of screening and letting patients go if their BP is under control without provider input and without a provider order. Is anyone able to give me some insight on this concern and if it is valid? It is something new, I understand there is hesitation when new things come about but I don't think I am asking anyone to do anything that will put their license at risk, but I would like to hear from the group. Thanks in advance!
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Sara Small BS RN
Hartford Hospital
Newington CT
(860)972-2154
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