Latest / Becker’s Healthcare Podcast / Community and Clinical Workflow Insights for Hypertension Care: Part 3

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Community and Clinical Workflow Insights for Hypertension Care: Part 3 · Becker’s Healthcare Podcast

• 0:00
  - Thanks so much for tuning in to the
• 0:01
  - Becker's Healthcare podcast.
• 0:03
  - This is the third and final episode of
• 0:05
  - a three part series produced in partnership with
• 0:08
  - the American Heart Association
• 0:10
  - community and clinical workflow insights for hypertension care.
• 0:14
  - In this episode, we're joined by Shay Slick,
• 0:17
  - the lead pharmacist
• 0:19
  - at Rx Care Charitable Pharmacy
• 0:21
  - at OhioHealth Riverside Community Medicine.
• 0:24
  - If you missed the first two episodes, we'd
• 0:26
  - encourage you to give them a listen to
• 0:28
  - as well.
• 0:30
  - Hello, everyone. My name is Shay Swick. I'm
• 0:32
  - the lead pharmacist at RxCare Charitable Pharmacy at
• 0:36
  - OhioHealth Riverside Community Medicine Clinic.
• 0:40
  - We're going to speak today about remote blood
• 0:42
  - pressure monitoring,
• 0:44
  - collaborative hypertension management, and internal medicine
• 0:47
  - primary care.
• 0:49
  - Our clinic is located in Columbus, Ohio as
• 0:52
  - a graduate medical education clinic.
• 0:55
  - So we are staffed by 54
• 0:58
  - internal med residents, seven attending physicians,
• 1:01
  - many nurses, medical assistants, and we have 2,100
• 1:05
  - internal med patients.
• 1:07
  - A large proportion of our patient panel is,
• 1:11
  - under insured. So
• 1:13
  - some about 20%
• 1:14
  - have no insurance,
• 1:16
  - 30%
• 1:17
  - or more have Medicaid.
• 1:18
  - And a lot of our patients do experience
• 1:21
  - housing and food insecurity and transportation
• 1:24
  - barriers.
• 1:25
  - So this can manifest in
• 1:27
  - effects on clinical outcomes. So our 2024
• 1:31
  - hypertension
• 1:31
  - control rate, which ranged between sixty and sixty
• 1:35
  - seven percent,
• 1:36
  - meaning over one third of our patients were
• 1:38
  - uncontrolled
• 1:39
  - with their hypertension.
• 1:41
  - So this has been a large area of
• 1:43
  - need at our clinic for many years.
• 1:45
  - And it just so happens that our charitable
• 1:48
  - pharmacy on-site at community medicine,
• 1:51
  - we've started a hypertension
• 1:52
  - program where we give free blood pressure monitors
• 1:55
  - to patients in need. We set up the
• 1:57
  - device, we educate the patient on their disease
• 2:00
  - state and their medications,
• 2:02
  - and we then monitor and follow-up with the
• 2:04
  - patient the next week.
• 2:06
  - So we thought, how can we expand this
• 2:09
  - program we have
• 2:10
  - further improve our hypertension outcomes and even potentially
• 2:14
  - bill for the service?
• 2:16
  - So this leads into our formal remote monitoring
• 2:19
  - project.
• 2:20
  - So our business plan was submitted in January
• 2:24
  - 2022
• 2:25
  - and took about two years for formal approval
• 2:27
  - just with a COVID backlog.
• 2:30
  - During 2024,
• 2:32
  - that's when the bulk of the project work
• 2:34
  - occurred.
• 2:35
  - So a lot of our IT data mapping,
• 2:38
  - meeting about workflow,
• 2:40
  - details, and then a lot of conversations with
• 2:43
  - our key stakeholders.
• 2:44
  - I will say, I think it's absolutely critical
• 2:47
  - to have a provider champion involved in a
• 2:50
  - project like this.
• 2:51
  - Last year, at the beginning of twenty twenty
• 2:53
  - five, we started our hypertension remote monitoring pilot
• 2:57
  - with formal project support.
• 2:59
  - And this whole time, our goal has really
• 3:01
  - been to improve hypertension
• 3:03
  - control through timely
• 3:05
  - data driven care.
• 3:06
  - So what does our workflow look like? Since
• 3:09
  - our pilot kicked off last year, we start
• 3:11
  - with an order from our provider.
• 3:13
  - So they order a blood pressure flow sheet
• 3:16
  - that appears in the patient's chart, and this
• 3:18
  - includes a formal pharmacist referral.
• 3:21
  - Our patients referred typically have established
• 3:24
  - uncontrolled hypertension
• 3:25
  - with readings above one thirty over 80.
• 3:28
  - We next go to an initiation
• 3:30
  - visit with the pharmacist. So, the pharmacist will
• 3:33
  - provide education,
• 3:34
  - whether that's disease state education,
• 3:37
  - thorough medication therapy management,
• 3:40
  - MTM.
• 3:41
  - And, of course, we set up the blood
• 3:42
  - pressure device, which is a device on loan.
• 3:46
  - We have weekly monitoring. So we get alerts
• 3:48
  - every week and the pharmacist and the residents,
• 3:51
  - we analyze data from the blood pressure flow
• 3:54
  - sheet. We outreach the patient. We make therapy
• 3:57
  - recommendations
• 3:57
  - and adjustments.
• 3:59
  - And this is where a collaborative practice agreement
• 4:01
  - with a pharmacist can come into play.
• 4:04
  - We bill monthly. So if we've received at
• 4:06
  - least sixteen days of blood pressure data in
• 4:09
  - a thirty day period,
• 4:11
  - that is billable.
• 4:12
  - The pharmacist documents and queues up the charge,
• 4:15
  - and then the provider is the billing
• 4:18
  - physician.
• 4:19
  - And then finally, when our patients are successfully
• 4:22
  - managed, their hypertension is under control per provider
• 4:25
  - assessment, they graduate from the program, they're able
• 4:28
  - to return the blood pressure loaner.
• 4:31
  - And at our charitable pharmacy, we do provide
• 4:33
  - a standard blood pressure cuff if a patient
• 4:35
  - is otherwise unable to obtain one through insurance.
• 4:39
  - So, as far as eligible patients,
• 4:41
  - I would say the biggest thing is truly
• 4:43
  - patient initiative.
• 4:45
  - If the patient is motivated,
• 4:47
  - we can really work with that. So a
• 4:49
  - few things that are required include the signed
• 4:52
  - order from the provider because that triggers the
• 4:55
  - blood pressure flow sheet. We do need the
• 4:57
  - patient to have a smartphone, and I will
• 4:59
  - say that has been a barrier, unfortunately.
• 5:02
  - We need them to have an email address,
• 5:03
  - but we can actually use a relative's email
• 5:06
  - if needed for account setup.
• 5:08
  - The patient does need to have a MyChart
• 5:10
  - account, which, again, we can assist with that.
• 5:13
  - The time commitment for an Apple iPhone setup
• 5:16
  - is about fifteen minutes or less.
• 5:19
  - Androids do take longer, especially if the patients
• 5:21
  - need to download apps and create accounts.
• 5:24
  - In the initiation visit, the pharmacist is setting
• 5:27
  - up the device, syncing
• 5:29
  - the necessary apps on the patient's phone to
• 5:32
  - the blood pressure device,
• 5:33
  - and then teaching the patient.
• 5:35
  - So, as mentioned previously, we do use the
• 5:38
  - provided education sheets.
• 5:41
  - We also provide medication therapy management.
• 5:44
  - So, in these initiation visits, we always target
• 5:47
  - blood pressure prescription adherence and counseling.
• 5:50
  - And when time allows and the patient is
• 5:52
  - willing, we will do a more comprehensive medication
• 5:55
  - review.
• 5:56
  - A few of the barriers that we do
• 5:58
  - experience sometimes in the early steps of the
• 6:00
  - process,
• 6:01
  - unfortunately, our IT team at OhioHealth, they were
• 6:04
  - unable to test Android phones in the formal
• 6:07
  - project, only iPhones.
• 6:09
  - So we've done a lot of research and
• 6:11
  - fine tuning on our own, but at this
• 6:13
  - point, we feel confident in, the process we
• 6:16
  - have.
• 6:16
  - When patients do not speak English, it can
• 6:19
  - be perceived as a barrier, but fortunately, our
• 6:21
  - clinic has the MARDI mobile interpreter devices.
• 6:25
  - And a lot of times the patients do
• 6:27
  - have relatives or caregivers
• 6:29
  - who are extremely helpful and very invested in
• 6:31
  - helping the patient get set up and then
• 6:34
  - even troubleshooting in the future.
• 6:36
  - And then also we've had our patient education
• 6:39
  - handouts
• 6:40
  - translated into some of the languages we commonly
• 6:42
  - see at our clinics, such as Somali,
• 6:45
  - Thuy, and Vietnamese.
• 6:47
  - The other barrier, probably the biggest barrier is
• 6:50
  - when the patient is unwilling.
• 6:52
  - But like we just mentioned, the staff triage
• 6:54
  - step that greatly helps that process.
• 6:57
  - Another important part of the initiation visit is
• 7:00
  - patient consent. So it's legally required that the
• 7:03
  - patient is aware that the service is billable.
• 7:06
  - So per our
• 7:07
  - terminology, insurance could be charged... Or sorry, insurance
• 7:11
  - would be charged and they may receive co
• 7:13
  - pays for services received. We've actually had no
• 7:16
  - patients complain of co pays to date though.
• 7:19
  - We do wanna let the patient know that
• 7:20
  - it's a loaner device,
• 7:22
  - and it must be returned to the office
• 7:24
  - upon graduation from the program.
• 7:26
  - They could be billed for the device, but
• 7:28
  - we also have not done that to date.
• 7:31
  - We also let the patient know that it's
• 7:33
  - not around the clock monitoring
• 7:35
  - and that if they do have concerns, their
• 7:38
  - blood pressures may be elevated or they have
• 7:40
  - concerning symptoms related to hypertension,
• 7:43
  - they should still call the provider's office or
• 7:45
  - seek emergent care.
• 7:47
  - So between our provider's smart set order and
• 7:50
  - our shared smart phrases,
• 7:52
  - we really cover all of our regulatory and
• 7:55
  - workflow requirements.
• 7:57
  - So as far as the remote monitoring,
• 7:59
  - this functions via Bluetooth technology.
• 8:02
  - We utilize the Omron seven series blood pressure
• 8:06
  - devices. These have form fitting cuffs,
• 8:09
  - which for most patients,
• 8:11
  - this does allow for a more accurate reading.
• 8:13
  - We are very grateful to the American Heart
• 8:15
  - Association
• 8:16
  - for their partnership. We were able to purchase
• 8:18
  - these monitors through funding in the collaborative.
• 8:21
  - We started with 20 arm cuffs and five
• 8:24
  - wrist cuffs.
• 8:25
  - And if you look to the right, you'll
• 8:27
  - see the sync steps for these blood pressure
• 8:29
  - monitors.
• 8:30
  - So first, we are focusing on syncing the
• 8:32
  - Omron blood pressure device to the app on
• 8:34
  - the patient's phone.
• 8:36
  - The Omron Connect app then syncs to the
• 8:38
  - health app on the patient's phone. So for
• 8:41
  - iPhones, this is Apple Health. For Androids, this
• 8:44
  - is Google Fit. And then the health app
• 8:46
  - syncs with MyChart.
• 8:48
  - Important to note, it does need to be
• 8:50
  - the specific MyChart app, not like a health
• 8:53
  - institution's app that links to MyChart.
• 8:55
  - And finally, the MyChart app syncs with the
• 8:58
  - blood pressure flow sheet.
• 9:00
  - This is how the data is transmitted to
• 9:01
  - the chart into the episodes tab,
• 9:04
  - which this is a glimpse of an enrolled
• 9:06
  - patient.
• 9:08
  - You can see systolic and diastolic blood pressure,
• 9:11
  - and then the bottom row is the heart
• 9:12
  - rate. If you look at May 13, you
• 9:15
  - can see that
• 9:17
  - patient checked, you know, 10 times or so.
• 9:20
  - We have some elevated readings. So this would
• 9:21
  - be a perfect example of, like, we would
• 9:24
  - want to go ahead and initiate patient outreach
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  - and see what was going on that day
• 9:28
  - and how we can assist and get to
• 9:29
  - the bottom of those issues.
• 9:31
  - At the top of this screen, you'll see
• 9:34
  - our patient clinical update. So, this is how
• 9:37
  - we get our weekly alerts on the patient
• 9:39
  - data. The alerts go into our message inbox
• 9:42
  - for the provider that ordered the flow sheet,
• 9:45
  - the primary care physician, which is the resident,
• 9:47
  - and then the pharmacist.
• 9:49
  - I did wanna give a little more detail
• 9:51
  - about OhioHealth's
• 9:52
  - collaborative practice agreement. So
• 9:55
  - for pharmacists in the ambulatory space, they can
• 9:58
  - work under a hypertension
• 10:01
  - CPA.
• 10:02
  - So these are used to really extend the
• 10:05
  - physician services and expand pharmacist care. It allows
• 10:08
  - the pharmacist to order labs and prescriptions
• 10:12
  - or titrate and adjust prescriptions as needed.
• 10:16
  - Megan Hull is our ambulatory clinical pharmacist at
• 10:19
  - Grant Family Medicine in Columbus,
• 10:21
  - and she is a true subject matter expert
• 10:23
  - in this area. So I encourage you to
• 10:25
  - reach out to her with any questions. She
• 10:27
  - is available in the chat currently.
• 10:30
  - At her clinic, they have loaned out 33
• 10:32
  - Omron blood pressure cuffs, and she's managed these
• 10:35
  - patients under the CPA.
• 10:37
  - Another practice in our Columbus area, doctor's family
• 10:41
  - practice, they've gifted or loaned 43 cuffs.
• 10:45
  - Alright. So now to dive into our remote
• 10:47
  - monitoring program statistics.
• 10:50
  - So from February '25 through February '26,
• 10:54
  - we enrolled forty two patients in the pilot.
• 10:57
  - Twenty one of these patients have graduated successfully.
• 11:00
  - So that's our fifty percent rate there. Twenty
• 11:03
  - one patients are still continuing monitoring.
• 11:06
  - This has been 24
• 11:07
  - iPhone using patients and 18 Android using patients.
• 11:11
  - The mean blood pressure at enrollment was about
• 11:14
  - one fifty two over 88.
• 11:16
  - The mean enrollment duration was just over three
• 11:19
  - months.
• 11:20
  - And the days of data that we received
• 11:23
  - in that period came to an average of
• 11:25
  - 43.7.
• 11:26
  - So that's about a 44%
• 11:28
  - data availability rate.
• 11:30
  - Our longest enrollment was just over eight months,
• 11:33
  - and that patient also had about a 50%
• 11:35
  - data transmission rate. Out of our 42 patients
• 11:38
  - in the program,
• 11:40
  - we've done 27
• 11:42
  - dose increases for antihypertensive
• 11:44
  - medications.
• 11:46
  - If you look down to the bottom of
• 11:47
  - this chart, you'll see the refilled missing medications.
• 11:51
  - So that was eight patients
• 11:53
  - who were actually prescribed an antihypertensive
• 11:55
  - medication,
• 11:57
  - but for some reason they stopped refilling it
• 11:59
  - or maybe they never picked it up from
• 12:01
  - their pharmacy.
• 12:02
  - So it was really kind of re prescribing
• 12:04
  - those antihypertensives
• 12:06
  - and encouraging the patient,
• 12:08
  - trying to remove some barriers to help them
• 12:10
  - get that medication.
• 12:11
  - So we've had a total of 70 therapeutic
• 12:14
  - interventions,
• 12:15
  - at least 84
• 12:17
  - educational interventions.
• 12:19
  - Each patient has had at least two touch
• 12:21
  - points with,
• 12:22
  - lifestyle modification
• 12:24
  - coaching,
• 12:25
  - comprehensive medication reviews with the pharmacist, and other
• 12:28
  - educational
• 12:29
  - outreaches.
• 12:30
  - So we've had at least 150
• 12:32
  - interventions with our patients.
• 12:33
  - As far as clinical outcomes, our measures were
• 12:37
  - baseline and graduation blood pressure,
• 12:39
  - average time to control, and then proportion achieving
• 12:42
  - control.
• 12:43
  - Our average time to control,
• 12:46
  - which we defined as the last transmitted blood
• 12:48
  - pressure reading or the office visit at which
• 12:51
  - the patient graduated from the program, it was
• 12:54
  - sixteen point two five days.
• 12:56
  - The average blood pressure at program completion was
• 12:59
  - one twenty one over 74,
• 13:02
  - and almost eighty one percent of our patients
• 13:04
  - achieved control.
• 13:05
  - The four patients that didn't technically achieve control
• 13:09
  - had an end average systolic blood pressure of
• 13:11
  - one thirty nine point five.
• 13:13
  - These patients either
• 13:15
  - refused,
• 13:16
  - medication therapy
• 13:17
  - or one patient was referred to nephrology. It
• 13:20
  - was a very complex case.
• 13:22
  - Or maybe the patient was just older and
• 13:25
  - had some clinical changes and it wasn't appropriate
• 13:27
  - any longer to continue.
• 13:29
  - But the change in blood pressure from baseline,
• 13:33
  - remember around one fifty two over 88 was
• 13:35
  - our blood pressure at baseline, it was a
• 13:37
  - 30.8
• 13:39
  - drop.
• 13:40
  - So decrease
• 13:41
  - in systolic blood pressure by about 20%,
• 13:44
  - and then about 16%
• 13:46
  - drop in diastolic blood pressure. And, of course,
• 13:49
  - the reason that we all do what we
• 13:50
  - do is for patient outcomes. We want our
• 13:53
  - patients' lives and their health to be better.
• 13:57
  - But it is important to share billing results
• 14:00
  - as well because this is what leads to
• 14:02
  - a sustainable program, ultimately.
• 14:04
  - So these are the CMS approved
• 14:06
  - CPT codes for remote physiologic monitoring.
• 14:10
  - You can see the Medicare physician fee schedule
• 14:13
  - from last year. For the first code, $994.53,
• 14:16
  - which was the setup charge,
• 14:19
  - we received about 98%
• 14:21
  - of the estimated charge for the 32 times
• 14:23
  - that we billed it. The next code, 99454,
• 14:27
  - that is the data transmission charge that can
• 14:29
  - be billed monthly.
• 14:31
  - We received,
• 14:32
  - $59.07
• 14:34
  - on average for the 99 times we build
• 14:36
  - that code. So that's actually 137%
• 14:39
  - of the estimated reimbursement.
• 14:42
  - 99457
• 14:43
  - is the patient management code. So you need
• 14:46
  - twenty minutes of patient interaction to be able
• 14:48
  - to bill this.
• 14:49
  - The 29 times we build this resulted in
• 14:52
  - an average reimbursement of just about a 100%.
• 14:55
  - The 99458
• 14:56
  - code is
• 14:58
  - twenty minutes more of patient management, so really
• 15:00
  - forty minutes. We billed that twice, but it
• 15:03
  - was to our OhioHealth financial aid plan, so
• 15:06
  - it was a write off. And then 99091
• 15:08
  - is chart interpretation and analysis.
• 15:11
  - We believe that some payers do not recognize
• 15:14
  - this this code, so we're investigating that currently.
• 15:18
  - So the financial impact really shows,
• 15:22
  - how effective remote monitoring can be.
• 15:24
  - We had 164
• 15:26
  - charges billed, which led to about $6,500
• 15:30
  - in reimbursement
• 15:32
  - through the Medicare physician fee schedule estimates.
• 15:35
  - This is an average of $191
• 15:37
  - per patient.
• 15:38
  - Some of the key payer takeaways from the
• 15:41
  - 19 plans billed is that Medicare pays about
• 15:44
  - 72 to 90%
• 15:46
  - for all RPM codes.
• 15:48
  - Medicaid pays 117%
• 15:51
  - for the data transmission charge,
• 15:53
  - and commercial payers in our area all pay
• 15:56
  - over 100%
• 15:57
  - for each RPM code,
• 15:59
  - even, up to 264%,
• 16:02
  - which kind of blew us away for the
• 16:03
  - data trans... Transmission charge.
• 16:05
  - Again, this really just is so important because
• 16:08
  - it leads to more sustainability
• 16:10
  - and more patients impacted.
• 16:12
  - So future directions, we want to integrate new
• 16:15
  - RPM codes that have been approved for 2026.
• 16:19
  - So 99445
• 16:21
  - allows for data transmission billing for fewer days
• 16:25
  - of data,
• 16:26
  - And then 99470
• 16:28
  - allows for billing for that ten to nineteen
• 16:31
  - minute patient interaction range.
• 16:33
  - We also wanna standardize our time tracking. So
• 16:36
  - we're working with our IT team on a
• 16:38
  - bot build that will automatically track time spent
• 16:41
  - in the patient's chart for remote monitoring.
• 16:45
  - We are currently expanding the program, so we
• 16:47
  - have 10 more arm monitors and five more
• 16:50
  - wrist monitors on order, And we're training more
• 16:53
  - staff to assist with the setup process.
• 16:56
  - We also would like to lateralize the program
• 16:58
  - to other Ohio health sites. So we have
• 17:01
  - trained the pharmacist and our other graduate medical
• 17:04
  - education clinics,
• 17:05
  - our congestive heart failure clinic at the hospital,
• 17:08
  - as well as our cardiometabolic
• 17:10
  - pharmacist.
• 17:11
  - And then we are considering for a future
• 17:13
  - state cellular enabled blood pressure devices.
• 17:16
  - These devices do not rely on Bluetooth technology,
• 17:20
  - Wi
• 17:21
  - Fi, patient smartphone.
• 17:23
  - So, these would be really great to remove
• 17:25
  - those barriers for even more patient reach. And
• 17:28
  - I have just this this graph once more.
• 17:31
  - So even though this green line shows us
• 17:34
  - at seventy one point three five percent hypertension
• 17:36
  - control, it's a large improvement from where we
• 17:39
  - were in 2024.
• 17:41
  - Our Ohio health system goal was increased last
• 17:44
  - year to eighty percent. So we are really
• 17:47
  - just wanting all of our efforts to align
• 17:49
  - to be able to to reach that goal
• 17:51
  - and maximize our patient outcomes.
• 17:53
  - Thank you all.
• 17:55
  - A big thank you to our sponsor for
• 17:56
  - the series, the American Heart Association.
• 17:59
  - You can find more Becker's Healthcare podcast anytime
• 18:02
  - by visiting our podcast page at beccarshospitalreview.com.
• 18:06
  - Thanks again for joining us, and thank you
• 18:08
  - for following along with our three part series,
• 18:11
  - community and clinical workflow insights for hypertension care.
• 18:14
  - Thank you.