This report provides an overview of lessons learned from the April 2012 Million Hearts™ Scaling and Spreading Innovation: Strategies to Improve Cardiovascular Health event sponsored by the AHRQ’s Health Care Innovations Exchange1, the CDC Division for Heart Disease and Stroke Prevention, and CMS, in partnership with the American Heart Association. This meeting was one of many events associated with the larger Million Hearts™ initiative.
Background on the Million Hearts™ Initiative
Million Hearts™ is a Department of Health and Human Services national initiative aimed at preventing 1 million heart attacks and strokes over a 5-year period from 2012 to 2017. This goal will be achieved by:
- Improving access to effective care;
- Improving the quality of care as related to Aspirin-Blood Pressure-Cholesterol-and Smoking (the ABCS);
- Focusing clinical attention on the prevention of heart attacks and strokes;
- Activating the public to lead a heart-healthy lifestyle; and
- Improving the prescription and adherence to appropriate medications for the ABCS.2
The Million Hearts™ initiative will focus, coordinate, and enhance cardiovascular disease prevention activities across the public and private sectors and demonstrate to the American people that improving the health system can save lives. Finally, Million Hearts™ will scale up proven clinical and community strategies to prevent heart disease and stroke across the nation.3
For more information on the Million Hearts™ initiative, visit http://millionhearts.hhs.gov.
“The 'what to do’ here is not rocket science. The ‘getting it done’ is harder than rocket science, but this is exactly the group to help us get started.”
Carolyn Clancy, AHRQ
On April 19, 2012, thought leaders from health care systems; federal, state, and local health organizations; health professional and patient organizations; payers and funders/investors; educational and research institutions; and more attended the invitation-only event, Million Hearts™ Scaling and Spreading Innovation: Strategies to Improve Cardiovascular Health. The event was designed to foster awareness of innovative ways to improve cardiovascular health and health care delivery and inspire creative thinking about scaling and spreading these cardiovascular innovations throughout the nation. The innovations featured in this event had been demonstrated to be effective. Given this premise, the goal of the day was to discover what it would take to foster broad implementation of these and other successful innovations in order to achieve the goals of the Million Hearts™ initiative.
The attendees were selected to represent the variety of perspectives that would need to work together for scale up and spread efforts to succeed. These stakeholders in cardiovascular health included government representatives, professional associations, insurers/payers, business groups, academic researchers, health care systems, and safety net providers. In Janet Wright’s opening remarks to the participants, she stated, “I will tell you you’re not here by accident. You were actually chosen because of your creativity and ingenuity, and your expertise, not only in your fields and in your organization’s mission, but actually in the ability to apply what you learn where it makes the most difference.” The participants shared real-world success stories on innovative health care service delivery activities that improved blood pressure and cholesterol levels. Facilitated by an innovative agenda, they brainstormed how to spread these successes in order to achieve better heart health in the nation. Appendix A shows the invitation issued, and Appendix B displays the participants who attended this event.
Carolyn Clancy, Director of AHRQ, and Thomas Frieden, Director of CDC, were featured keynote speakers. The event day was divided into three major sections. The morning was devoted to four “fishbowl” sessions, each focusing on an evidence-based innovation on heart health. In the afternoon, the sessions changed focus, moving from specific innovations to broader questions about scaling and spreading health care innovations. Attendees were invited to participate in three “buzz sessions,” each devoted to a broad question related to scale up and spread. The day ended with a “3x5” activity to identify the best ideas generated during the day. The full agenda for the event is available in Appendix C.
The event started with a plenary “fishbowl” session involving all participants, followed by three concurrent sessions. The four innovations featured in the fishbowl sessions differed in their core elements, implementation settings, and the extent to which they had scaled up and spread these novel practices.
The fishbowl format involved an innovator presentation to a reactor panel whose members represented specific stakeholder perspectives. The panels posed questions and offered guidance to the innovators about issues they might consider in further efforts to spread their innovations.These dynamic sessions identified a range of important issues and challenges to scale up and spread that could be generalized to other efforts to expand innovative practices in cardiovascular health. These conversations were staged in a metaphorical fishbowl, with other participants observing and contributing actively to the discussion.
Brief summaries of the innovations follow below:
- Heart360®: In this pharmacist-led, home blood pressure monitoring program implemented in Kaiser Permanente Colorado, participants upload their home blood pressure measurements 3 to 4 times a week to the American Heart Association’s Heart360® Web site. Innovator David Magid described how clinical pharmacy specialists monitor the patients’ blood pressure readings and adjust medication therapy as needed. This program, which has spread to Kaiser Permanente Southern California, has led to improved blood pressure control, increased reduction in blood pressure, and improved patient satisfaction with care for patients with uncontrolled hypertension.
- Disease Management to Promote Blood Pressure Control Among African Americans: The purpose of this innovation was to improve blood pressure among African Americans in the Aetna health plan, using a telephonic nurse disease-management program. René Vega described the results of this program: decreased systolic blood pressure and increased frequency of blood pressure self-monitoring among the participants. The program design was combined with another similar pilot study and expanded to Aetna’s Medicaid population.
- Language Concordant Health Coaches: This program was implemented in the San Francisco General Hospital Family Health Center. Health coaches who speak the patient’s preferred language team with residents to improve the self-management skills and quality of care of patients who have limited English proficiency and health literacy. Innovator Hali Hammer described how health coaches conduct a pre-visit meeting, assist during the medical visit, conduct a post-visit meeting, and follow up with the patient 1 to 2 weeks after the visit to offer additional support. The program has led to improvements in the treatment process and clinical outcomes of patients with diabetes, including improved blood pressure and cholesterol levels.
- Medication Therapy Management: The North Carolina Pharmacists Association's Asheville Project created a community-based, medication therapy management (MTM) program initially for patients with diabetes and subsequently for hypertension/dyslipidemia, asthma, and depression. As described by one of the innovators, Barry Bunting, the pharmacist-based program resulted in both clinical benefits (i.e., reduced hemoglobin A1C levels, improved blood pressure control, and significant declines in cholesterol and serum triglyceride levels) and financial benefits (i.e., reduced costs across four targeted conditions: diabetes, asthma, cardiovascular disease, and depression; and a positive return on investment). The program has expanded nationally with the support of several organizations, including (but not limited to) American Health Care and the American Pharmacists Association Foundation.
For more information on each of the fishbowls, including a list of the presenters, moderators, reactor panel members, as well as links to the presentations and profiles from the AHRQ Health Care Innovations Exchange, see Appendixes D-G.
In the afternoon, participants joined moderated discussion groups (“buzz sessions”) to discuss general issues related to scaling and spreading health care innovations. Participants were invited to move freely across buzz sessions, depending on their interest in the open-ended discussions. The sessions explored the following questions:
- How can innovators proactively promote the spread of their innovations? What skills and support do they need to be successful?
- What do potential adopter organizations need to facilitate their uptake of healthy heart innovations?
- How can government and private institutions work together to promote the spread and adoption of healthy heart innovations?
In a highly interactive closing activity, participants were asked to identify and rate the best ideas of the day in an exercise using 3x5 index cards. The goal was to identify the top ideas to support scale up and spread activities related to the Million Hearts™ initiative. To view these top ideas, see Appendix H.
This report summarizes the key themes that emerged from the April 2012 event. The report, based primarily on the transcripts of the fishbowls and buzz session discussions, is organized along the following topics:
- How to prepare innovations that further the Million Hearts™ initiative for spread;
- Differences between the roles of Innovators and Spreaders and how to connect the two;
- Necessity of engaging multiple stakeholders in spread efforts;
- Considerations for implementing Million Hearts™ innovations in various health care settings; and
- How to spread Million Hearts™ innovations in a changing health care environment.
1 The Agency for Healthcare Research and Quality (AHRQ)’s Health Care Innovations Exchange is a central repository of health care service delivery and policy innovations. It features profiles of successful and attempted innovations that describe the innovative activity, its impact, how the innovator developed and implemented it, and other useful information for deciding whether to adopt the innovation. AHRQ’s Health Care Innovations Exchange is available at: http://innovations.ahrq.gov.
2 Million Hearts™: The Initiative. http://millionhearts.hhs.gov/aboutmh/overview.html
3 Million Hearts™: The Initiative. http://millionhearts.hhs.gov/aboutmh/overview.html