MMHA 6530 Week 11 Hypertension Program Proposal Example

Bluestem Health Network Hypertension Care Management Program: Proposal for a Two-Year Start in the Remote Counties

Student Name

Walden University

MMHA 6530: Disease Prevention and Care Management

Instructor Name

Month Day, Year

Bluestem Health Network Hypertension Care Management Program: Proposal for a Two-Year Start in the Remote Counties

Request

Bluestem Health Network requests approval to launch a hypertension care management program for adults whose blood pressure is uncontrolled or who have not had a reading in a year, beginning in the two most remote counties and expanding to the other three as process targets are met. The program would employ four community health workers, one clinical pharmacist and one nurse lead, with part-time analytic support, for an initial two years. The two-year cost, built from these positions and home monitoring equipment, is presented in the budget section in illustrative figures for the finance committee to confirm. The decision needed is approval of the positions and the expansion rule at the next board meeting, so that recruitment can begin and the first patients can be enrolled within four months.

The Prevention Case

Blood pressure control is secondary and tertiary prevention at once: it prevents the complications of hypertension, chiefly stroke, heart failure and kidney disease, among adults who already have the condition (Leavell & Clark, 1965). No condition appears in more of Bluestem's registry records than hypertension, and the hospital's stroke and heart failure admissions trace back to it again and again. National data show control declining after years of improvement (Muntner et al., 2020). Bluestem's prevention portfolio has vaccines, screening reminders and a heart failure clinic for advanced disease, but nothing for the thousands of adults with diagnosed hypertension who are uncontrolled or unseen.

Burden and Enrollment

Of Bluestem's 9,600 adults with hypertension, roughly half have controlled pressure, while the rest split between high last readings and no reading at all for a year or more, with the unseen concentrated in the remote counties. After exclusions that follow the HEDIS measure (National Committee for Quality Assurance, 2024) and two program exclusions, about 4,480 adults are eligible. The program enrolls unseen adults first, then uncontrolled adults with no visit booked, then those with a visit booked. In year one it can enroll about 1,440 adults, beginning with the 800 unseen adults in the remote counties.

Care Model, Staffing and Workflow

The program follows a disease management model suited to a large population with one main condition. Community health workers find patients, often through family and community contacts, loan home blood pressure monitors and support twice-daily readings. Home monitoring with clinical support improves control (Uhlig et al., 2013). When home readings run high, a clinical pharmacist changes medications within limits the network's physicians have signed off, and the patient's own clinician hears of every change, a pattern that improved control in a randomized trial (Margolis et al., 2013). A nurse lead supervises the workers and handles urgent readings. Team-based care of this kind has improved blood pressure control in many settings (Carter et al., 2009), and community health workers have shown benefits in rigorous trials (Kangovi et al., 2020).

Budget

Table 1 builds the two-year cost from positions and equipment. Figures are illustrative and will be replaced with current salary scales and vendor quotes.

Table 1

Two-Year Program Budget (Illustrative)

Note. Expected billing and bonus offsets are excluded from the totals until confirmed.

Funding

Bluestem's own budget pays for the six core positions. Medicare chronic care management billing, once compliance confirms which staff time qualifies, and Medicare Advantage quality bonuses tied to blood pressure control will offset part of the cost over time (Centers for Medicare & Medicaid Services, 2024). These offsets are reported separately each year and are not used to justify the positions at the start.

Measurement and Expansion Rule

Control is reported twice each quarter, among everyone enrolled and across the network's whole hypertensive population using the HEDIS specification, so that the program cannot look good by enrolling easy cases. Process measures follow the three links in the chain: finding unseen patients within a month, getting readings back from home and acting on high readings within days. A balancing measure watches primary care appointment waits (Provost & Murray, 2011). The program adds counties only when reach and home reading targets have been met for two consecutive quarters, so growth follows evidence.

Resolved Assumptions

Table 2 shows how each item in the draft's assumption register was settled.

Table 2

Resolved Assumptions (Illustrative Outcomes)

What the Revisions Mean

Two assumptions changed the plan. The caseload for remote-county workers fell from about 120 to 100 because travel takes longer than expected, which reduces first-year enrollment from about 1,440 to about 1,320 adults; the remote counties' unseen patients are still covered in full. Billing for pharmacist time remains uncertain, so projected offsets are lower. Neither change alters the request, though both lower the first year's expectations slightly, which the board should hear plainly rather than discover at the first quarterly report. The board is asked to approve the positions, the budget and the expansion rule, and to review the first year's measures before the second year's expansion begins. If the board prefers a smaller start, the program could begin with two community health workers in the remote counties and the pharmacist, adding the other positions after six months; that option would delay reaching the other counties but would still test the model where the need is greatest.

References

Carter, B. L., Rogers, M., Daly, J., Zheng, S., & James, P. A. (2009). The potency of team-based care interventions for hypertension: A meta-analysis. Archives of Internal Medicine, 169(19), 1748-1755. https://doi.org/10.1001/archinternmed.2009.316

Centers for Medicare & Medicaid Services. (2024). Chronic care management services (MLN909188). Medicare Learning Network.

Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. Health Affairs, 39(2), 207-213. https://doi.org/10.1377/hlthaff.2019.00981

Leavell, H. R., & Clark, E. G. (1965). Preventive medicine for the doctor in his community: An epidemiologic approach (3rd ed.). McGraw-Hill.

Margolis, K. L., Asche, S. E., Bergdall, A. R., Dehmer, S. P., Groen, S. E., Kadrmas, H. M., Kerby, T. J., Klotzle, K. J., Maciosek, M. V., Michels, R. D., O'Connor, P. J., Pritchard, R. A., Sekenski, J. L., Sperl-Hillen, J. M., & Trower, N. K. (2013). Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: A cluster randomized clinical trial. JAMA, 310(1), 46-56. https://doi.org/10.1001/jama.2013.6549

Muntner, P., Hardy, S. T., Fine, L. J., Jaeger, B. C., Wozniak, G., Levitan, E. B., & Colantonio, L. D. (2020). Trends in blood pressure control among US adults with hypertension, 1999-2000 to 2017-2018. JAMA, 324(12), 1190-1200. https://doi.org/10.1001/jama.2020.14545

National Committee for Quality Assurance. (2024). HEDIS measurement year 2024: Volume 2, technical specifications for health plans. National Committee for Quality Assurance.

Provost, L. P., & Murray, S. K. (2011). The health care data guide: Learning from data for improvement. Jossey-Bass.

Uhlig, K., Patel, K., Ip, S., Kitsios, G. D., & Balk, E. M. (2013). Self-measured blood pressure monitoring in the management of hypertension: A systematic review and meta-analysis. Annals of Internal Medicine, 159(3), 185-194. https://doi.org/10.7326/0003-4819-159-3-201308060-00008