Primary Care Clinics Collaborate

November 2015

​​Primary Care Clinics Collaborate to Better Serve Patients with Hypertension 

Although they operate as separate and independent clinics, primary care providers at University of Colorado Health have banded together to elevate the care patients receive by improving workflow and developing protocols that increase clinical effectiveness. It was with this goal in mind that internal medicine and family medicine clinics began working on improving outcomes for patients with hypertension.

According to Carmen Lewis, MD​, hypertension was chosen because 1) it’s a common condition—according to the American Heart Association, approximately 80 million U.S. adults have been diagnosed with high blood pressure, and 2) there’s good evidence that shows treating people with high blood pressure saves lives. As practice director of Lowry Internal Medicine and Anschutz Internal Medicine Clinics, Dr. Lewis is working with medical assistants, nursing staff and pharmacy to improve outcomes for their patients.

“It’s a problem across our country, yet in general, we’re not doing a good job. It’s why we’ve taken the initiative to do something about it,” said Dr. Lewis. 

In order to improve hypertension across clinics, a team effort is required. Everyone has a role in helping hypertensive patients. And the first step is ensuring the ability to track and monitor data. 

“We’ve been able to validate our reports to make sure our data is accurate. We are modifying our workflows and following our data over time to see if we’re improving,” she said. 

Developing a sustainable, team-based outreach system for hypertensive patients comes with a unique set of challenges.

Corey Lyon, DO, is medical director of AF Williams Family Medicine Center at Stapleton. “It’s a challenge to reach out to patients to assure follow-up and blood pressure recheck is completed,” he explained. “We rely on patients returning to clinic on their own, which means we are losing patients in follow-up.” 

Dr. Lewis agrees. “When we have enough staff, we want to manage people outside of the office visit,” she said. “We think we could get improvement in our rates of control by engaging patients outside of the visit.” 

Improving quality of life for patients remains the team’s priority. 

“The guidelines recently changed, and patients were age-stratified. Those who are a little older have different control goals, and we’re making sure we’re not over-treating people,” said Dr. Lewis. 

As for the future, the primary care clinics will continue to collect data to establish benchmarks and seek resources that will enable them to better serve the hypertensive patient population. 

“The truth is we could be doing more. But we need more resources for outreach and reporting,” said Dr. Lewis.

“We’d like to be doing interactive follow-up calls by team members, such as a clinical pharmacist, to assure patients received and are taking and tolerating their medication,” Dr. Lyon said. He also cites the use of health coaches, who can help patients set and meet goals surrounding diet and other behavior modifications.

Beyond resources, innovation is needed. “Our health system is still heavily dependent on the patient being seen in clinic, but to better support this population, we need to expand the way we provide patient care to beyond the walls of the clinic,” said Dr. Lyon.