Slide 1

Thank You Janet

Slide 2

ABCS of Heart Disease and Stroke Prevention Our Challenge Our Partners Jacquie Halladay MD MPH, UNC-CH Lindsay Beavers, CCME

Slide 3

ABCS of Heart Disease and Stroke Prevention Aspirin: Increase low dose aspirin therapy according to recognized prevention guidelines. Blood pressure: Prevent and control high blood pressure; reduce sodium intake. Cholesterol: Prevent and control high blood cholesterol. Smoking: Increase the number of smokers counseled to quit and referred to State quit lines; increase availability of no or low-cost cessation products.

Slide 4

http://www.cdc.gov/DHDSP/programs/nhdsp_prog ram/docs/ABCs_Guide.pdf

Slide 5

National Heart Disease and Stroke Prevention (NHDSP) Program Anchored in the Socio-ecological Model.

Slide 6

Use strategies that.. Are evidenced based. Have broad reach and impact to general and priority populations. National Heart Disease and Stroke Prevention Program - Strategies for States to Address the ABCS

Slide 7

Linked to Policy and Systems Change outcome measures

Slide 8

Objectives: to understand. The components of the ABCS. Partners in NC. How are we are addressing the ABCS at various levels of the Socio-ecological Model in NC.

Slide 9

Plan Review ABCS Media materials and evaluation plans (CCME) Next Steps Heart Healthy Lenoir Project Discuss coaching as a self management support resource (State Health Plan and CCNC Medical Home) Briefly discuss the Community Transformation Grant (CTG) activities (NC DPH)

Slide 10

HDSP- CCME - Heart Lessons

Slide 11

The ABCS of Heart Disease and Stroke Prevention Janet Reaves Memorial Conference February 3, 2012

Slide 12

Television Education Campaign Target audience: Adults, 45 years of age and older, who have an annual household income below $100,000 The commercial will focus on the ABCS, which is a national CDC campaign. The new commercial will air for 4 weeks in February 2012 on cable and network television across the state, covering media markets in Greenville, Raleigh, Greensboro, Charlotte, and Asheville. Estimated potential impressions: 5,429,818 The media buy was based on Nielsen Ratings.

Slide 13

Television Education Campaign, cont. Storyboard Focus Groups Three focus groups tested three different concepts for the commercial. The spot entitled Heart Lessons was chosen. Participants: At least 12 participants per group Equal number of ethnic majority and minority participants, male and female 45 years or older Household incomes below $40,000 All were residents in counties east of I-95, where the highest burden of heart disease and stroke exists

Slide 14

2012 Television Education Campaign Evaluations Measurement 600 pre- and post-campaign surveys will be conducted. This process was designed to specifically determine the impact of the TV advertising campaign in the eastern counties of NC. Methodology Surveys will be conducted through telephone interviews. Surveys will measure impact of public awareness on ABCS, prevention measures, and advertisement.

Slide 15

SWYH Banner Ads SWYH banner page on the SWYH website www.startwithyourheart.com Home > Health Professionals > SWYH Banners

Slide 16

Educational Material, cont. Other materials: 8,000 blood pressure index cards 5,000 consumer ABCS flyers 7,500 stroke magnets

Slide 17

Educational Material Brochures on stroke, blood pressure, and cholesterol have been printed and provided to health coordinators.

Slide 18

Media Outreach Sodium op-ed was published in the N&O on December 23, 2011. http://www.newsobserver.com/2011/12/23/17285 02/cut-the-salt-and-help-your-health.html http://www.newsobserver.com/2011/12/23/17285 02/cut-the-salt-and-help-your-health.html Circulation/distribution total: 144,075 High blood pressure and Cholesterol op-eds in progress SWYH promotional messages distributed via the CCME QP Online newsletter, Facebook and Twitter pages, and the CCME website.

Slide 19

Community Outreach Activities Conduct outreach activities in 2012, predominantly in eastern North Carolina February 2012 o Provide ABCS flyers to be distributed at a Go Red Gala in Greenville on Feb. 5 o Provide an ABCS insert for church bulletins to 35 churches in eastern NC through Cornerstone Ministries May 2012 o Send ABCS flyers to 21 Wal-Mart pharmacies in eastern NC to distribute to their patients

Slide 20

Questions? 100 Regency Forest Drive, Suite 200, Cary, NC 27518 800.682.2650 www.thecarolinascenter.org

Slide 21

Heart-Healthy Lenoir Blood Pressure Control Project: ECU / UNC-Chapel Hill PIs: Alice Ammerman, Darren DeWalt, Cam Patterson

Slide 22

HTN office intervention team Darren A. DeWalt, MD, MPH - PI Skip Cummings, PharmD Katrina Donahue, MD, MPH Beverly Garcia, MPH Jacquie Halladay, MD, MPH Alan Hinderliter, MD Cassie Miller, MPH Crystal Wiley-Cene, MD, MPH

Slide 23

Goals for the Hypertension Control Project Reduce blood pressure levels among patients with poorly controlled hypertension. Reduce disparities in blood pressure by race and by literacy. Create systems that can sustain these improvements within current primary care practice.

Slide 24

Stanford-USFC EBPC Performed a systematic reviews of interventions aimed at reducing BPs among people with HTN.

Slide 25

Methods: Stanford-UCSF EBPC Search the literature from 1980 to 2003 regarding QI and BP reductions strategies Restrict to interventions targeting provider behavior*/organizational change. * separate review performed on patient only interventions

Slide 26

Classification of Interventions classificationsexamples Provider EducationMaterials/instructions given to providers regarding appropriate care Provider RemindersPrompts to providers to perform specific care tasks Provider Audit and FeedbackClinical performance reports Facilitated relay of clinical data to providers Patient clinical data transmitted from home BP cuffs etc. Patient EducationMaterials/instructions regarding HTN Patient RemindersAppointments, adherence Promotion of self managementAccess to resources/devices Team ChangeAdditions of role changes Financial IncentivesReimbursement structure changes

Slide 27

Classification of Interventions classificationsexamples Provider EducationMaterials/instructions given to providers regarding appropriate care Provider RemindersPrompts to providers to perform specific care tasks Provider Audit and FeedbackClinical performance reports Facilitated relay of clinical data to providers Patient clinical data transmitted from home BP cuffs etc. Patient EducationMaterials/instructions regarding HTN Patient RemindersAppointments, adherence Promotion of self managementAccess to resources/devices Team ChangeAdditions of role changes Financial IncentivesReimbursement structure changes

Slide 28

For instance.. Patient Interviews: HTN awareness (seriousness, know their # s) Barriers to taking medication. Ideas on home BP monitoring method (HBPM). Perceived healthcare disparities (race/ethnicity/literacy level/SES). Ideas on phone or office self- management support coaching program.

Slide 29

Current work: Develop and implement the phone coaching program. Evidence regarding effectiveness NC programs

Slide 30

Evidence for phone coaching Hutchison et al. 2011 >1000 studies (Randomized controlled trials) 41 trials - 34 phone coaching services. Wide variety of coaching models on several different diseases. Overall the evidence supports that phone coaching is an effective intervention especially for chronic cardiovascular conditions and diabetes..with the most notable benefits including..

Slide 31

Phone Coaching Improved patient compliance with self care regimens. Increased patient confidence towards disease management. Reduced hospital readmissions Improved mental health

Slide 32

Coaching activities ..Adjunct to provider care, not a replacement Medication review (purpose, side effects) Involve family members and friends as support Assist with empowerment (role play) Augment problem solving skills Discuss food labels, low sodium options Provide follow-up post hospitalization to ensure understanding of medication regimen and to see that a follow-up provider visit is scheduled Goal setting Smoking cessation/behavioral counseling Many more..

Slide 33

NC Health Smart http://www.shpnc.org/ncHealthSmart/faq-nchs-health- coach.aspx www.shpnc.org

Slide 34

NC Health Smart

Slide 35

Coaching from the NC from the State Health Plan! Weight control Yall calling and know that you're going to call is really motivating for me. Lost 22 pounds Improved diabetes control A1c from 10.7 to 7.0% Control of BP. Medication adherence and with resulting BPs from 177/92 to 124/70!

Slide 36

Coaching from the NC from the State Health Plan! Assistance with understanding symptoms of an acute MI. Connected with patient post hospitalization and started working with her on how to manage her medications and laboratory testing post MI. The Graduate. Fasting BGs from 160 to 70mg/dl.

Slide 37

Phone coaching : Duke team(s) Hayden Bosworth, PhD Nurse lead phone coaching programs in NC. Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Center for Aging and Human Development, Duke Hypertension Center, and Duke Clinical Research Institute.

Slide 38

Bosworth et al. - Improved BP control 475 patients from 32 zip codes around Duke, 2 year intervention. Strategy: phone coaching targeting HTN behaviors +/- home BP monitoring. Bottom line: Improved BP control at minimal costs (~ $400 dollars per year including BP monitors and bi-monthly coaching calls).

Slide 39

Bosworth and CCNC - Adherence. QI approach in 3 CCNC networks. Measured pharmacy fill rates for HTN meds MPR. 6 month intervention for 558 patients. Called every 3 weeks for a max of 10 calls. Encounters included core modules - addressed each time (adherence and medication tolerance. AND additional modules activated at specific times (diet, HTN knowledge, social support).

Slide 40

Bosworth and CCNC - Adherence Those with at least one call improved their medication adherence scores. And had higher fill rates than non- participants. Medication Possession Ratios: very poor if the ratio is < 0.6 poor if 0.6-0.8 good if 0.8

Slide 41

Average Medication Adherence Overtime: (a) intervention group vs. (b) usual care Intervention Start a b Participants - MPR: 59% to 77% NON-participants - MPR: 60% to 64%

Slide 42

Adherence compared to themselves Intervention Start Very Poor Poor Good

Slide 43

More coaching partners.. People like Dr. Jonathan Rubens from ActiveHealth management.

Slide 44

44 Health Plans, Hospitals, Health Systems

Slide 45

45 Employers Westinghouse UPS TVA IUOE

Slide 46

Socio-ecological Model

Slide 47

First of its kind in Brunswick Co.

Slide 48

Slide 49

Slide 50

Slide 51

North Carolina Community Transformation Grant

Slide 52

Strategic Directions TobaccoFree Living Active Living and Healthy Eating High Impact Quality Clinical and Other Preventive Services (HTN and Cholesterol)

Slide 53

Policy, Environment, Programmatic, and Infrastructure Change Policy Educate the public and stakeholders about policy interventions to improve population health Environment create social and physical environments that support healthy living Programmatic Increase access to prevention programs to support healthy living Infrastructure Change systems, procedures, and protocols within communities and institutions that support healthy behavior

Slide 54

Core Principles Maximize health impact through prevention Advance health equity and reduce disparities Use and expand the evidence base

Slide 55

North Carolina Strategies TobaccoFree Living Increase smoke-free regulations of local government buildings and of indoor public places. Increase tobacco-free regulations for government grounds, including parks and recreational areas. Increase smoke-free housing policies in affordable multi- unit housing and other private sector market-based housing. Increase the number of 100% tobacco-free policies on community colleges campuses and state and private university/college campuses.

Slide 56

North Carolina Strategies Active Living Increase the number of convenience stores that increase the availability of fresh produce and decrease the availability of sugar-sweetened beverages. Increase the number of communities that support farmers markets, mobile markets, and farm stands. Healthy Eating Increase the number of communities that implement comprehensive plans for land use and transportation. Increase the number of community organizations that promote joint use/community use of facilities.

Slide 57

North Carolina Strategies High Impact Quality Clinical and Other Preventive Services (High Blood Pressure and Cholesterol) Increase the number of health care providers quality improvement systems for clinical practice management of high blood pressure and high cholesterol, weight management and tobacco cessation. Increase the number of healthcare organizations that support tobacco use screening and referral to cessation services.

Slide 58

North Carolina Strategies Increase the number of community supports for individuals identified with high blood pressure/cholesterol and tobacco use (e.g. Chronic Disease Self- Management Programs, (CDSMP) weight management programs, tobacco cessation programs).

Slide 59

CTG Regions 59

Slide 60

Slide 61

Heart Healthy Lenoir Project P-50 Goals: Understand factors that lead to worse health in Lenoir County. Understand factors that lead to disparities within Lenoir County. R01- Patterson: Study genetic footprints that affect treatment success. R01- Ammerman/Keyserling: Test a sustainable program to improve nutrition/physical activity and support weight loss. R01- DeWalt: Test a system to improve blood pressure control through primary care practices.

Slide 62

Control of High Blood Pressure and High Blood Cholesterol-Strategies Strategies- Primary Care Health Systems Promote systems to support self- management (e.g., telephonic follow-up, linkages to home monitoring, self- management programs). Promote system changes that integrate and sustain use of community health workers and other healthcare extenders within healthcare settings.

Slide 63

Timeline Yr 1 5/10-4/11 Yr 2 5/11-4/12 Yr 3 5/12-4/13 Yr 4 5/13-4/14 Yr 5 5/14-4/15 Get to know patients and practices Enroll 600 Implement/Test New Strategies Track Outcomes Analyze results

Slide 64

Role of Hypertension in CVD HTN accounts for 27% of total CVD events in women and 37% in men 60% of those with known HTN are on medical therapy 50% of those on therapy are at their goal BP Controlling BP reduces the risk of stroke (35-40%), myocardial infarction (20-25%), and heart failure (50%) Chobanian et al. JAMA. 2003; 289:2560-2572. Jajjar and Kotchen. JAMA. 2003; 290:199-20.

Slide 65

HTN, It is important. WHO: credits HTN with 1 in every 8 deaths It is the 3rd leading cause of death worldwide The most important public health problem in developed countries. Agency for Healthcare Research and Quality. Technical Review 9. January 2005. Controlling hypertension is the single most effective clinical service for reducing mortality Farley TA Am J Prev Med 2010