MMHA 6530 Week 5 Enrollment Criteria Analysis Example

From 9,600 Adults to a First-Year Caseload: An Enrollment Funnel for Bluestem's Hypertension Program

Student Name

Walden University

MMHA 6530: Disease Prevention and Care Management

Instructor Name

Month Day, Year

From 9,600 Adults to a First-Year Caseload: An Enrollment Funnel for Bluestem's Hypertension Program

Purpose

Bluestem Health Network's hypertension program, which the Week 4 memo placed under the disease management model, with outreach workers and a pharmacist doing most of the work, cannot serve every adult with hypertension in its first year. This analysis builds an enrollment funnel: it starts with the full population from the Week 3 burden brief, removes adults who should not be in the program, defines who is eligible, orders the eligible into priority tiers and compares the result with the team's capacity. All counts are illustrative, rounded and drawn from a composite registry.

The Funnel

Table 1 shows each step and the number of adults remaining.

Table 1

Enrollment Funnel (Illustrative Counts)

Exclusions

The first set of exclusions follows the HEDIS Controlling High Blood Pressure measure, which removes adults in hospice or palliative care, adults with end-stage kidney disease and pregnant women from its denominator (National Committee for Quality Assurance, 2024). Using the same exclusions keeps the program's results comparable with the measure the network already reports.

Two exclusions are the program's own. Adults already in the heart failure transitional care program are excluded because that program manages their blood pressure as part of a more intensive plan, and enrolling them twice would duplicate calls and confuse patients about whom to contact. Adults under active care of a kidney specialist are excluded because their blood pressure targets and medications are often set by the specialist, and a pharmacist adjusting medications under a primary care protocol could conflict with that plan. Both exclusions should be revisited after the first year: some heart failure patients leave the transitional program after 90 days and may then need disease management.

Eligibility and Tiers

Adults are eligible if their latest blood pressure is 140/90 or higher or if they have no reading in the past twelve months. About half of the remaining population meets one of these conditions. Because the program cannot reach everyone in the first year, the eligible are ordered into tiers.

Tier 1: unseen. Adults with no reading in twelve months come first. The burden brief found them concentrated in the two most remote counties, where clinic-based care has not reached them. They are the group the program is best placed to help, since community health workers can visit them and loan home monitors.

Tier 2: uncontrolled with no follow-up booked. Adults whose last reading was high and who have no upcoming visit are at risk of drifting into the unseen group. Outreach can reconnect them before that happens.

Tier 3: uncontrolled with a follow-up booked. Adults who are uncontrolled but have a visit scheduled already have a planned point of contact. They are lowest priority for outreach, though the pharmacist may still review their medications before the visit.

Capacity

Table 2 compares the tiers with the team's estimated first-year capacity.

Table 2

First-Year Capacity Against Tiers (Illustrative)

What Capacity Means

With four community health workers, the program can enroll about 1,440 adults in its first year. That covers all of Tier 1 in the two remote counties, about 800 adults, and leaves room for about 640 more, drawn from Tier 1 in the other counties. Tier 2 and Tier 3 will not be reached by outreach in year one, though clinic staff can continue to manage them in regular visits. The pharmacist is the tighter constraint: about 1,000 medication reviews a year means that not every enrolled patient can have one, so the pharmacist will review patients whose home readings remain high after the first month.

Home monitoring makes this design workable in remote counties, since patients can submit readings without traveling. Self-measured blood pressure monitoring improves control, particularly when paired with clinical support that acts on the readings (Uhlig et al., 2013).

Fairness and Revisiting the Rules

Ordering by tier means some uncontrolled adults wait. That is a cost the network should acknowledge rather than hide. The rationale is that unseen adults in remote counties have the least access to any other help, while uncontrolled adults with visits booked have at least one planned contact. Team-based hypertension care tends to produce its largest improvements among patients who are not controlled at the start (Carter et al., 2009), which supports prioritizing those the clinic has lost track of. The tiers should be reviewed every six months, as Tier 1 shrinks and capacity is known more precisely, and the exclusions after one year.

Data Steps and Checks

The funnel will be rebuilt monthly from the registry, so that patients move between tiers as their status changes. A Tier 2 patient who misses a planned visit becomes Tier 1 after twelve months without a reading; a Tier 1 patient whose community health worker obtains a home reading moves to controlled or uncontrolled. Each month the population health analyst will check three things before the list goes to the team: that exclusions were applied using current problem lists, that readings from outside sources such as pharmacies are included when recorded, and that no patient appears on more than one program's list. The analyst will also report how many patients left the funnel each month and why, so the team can see whether people are being lost between steps. A funnel that is built once and never rebuilt quickly stops describing the population it was meant to serve.

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

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

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