Using Appreciative Inquiry to help the Lehigh Valley’s adult Hispanic population at risk for high blood pressure and its comorbidities
Centro de Salud (CDS), an Internal Medicine health center treating the region’s Hispanic-Latino patient population, serves the highest risk patients across all internal and family medicine practices at Lehigh Valley Health Network (LVHN) and Valley Health Partners Community Health Center (VHPCHC). About 25% of the patients at CDS have high blood pressure, and the rates of awareness and control are low. These patients are also subject to multiple comorbidities impacted by various social determinants of health, putting them at further risk for developing complications related to their uncontrolled hypertension.
A project with a goal and purpose
Practice lead at CDS, Orlando Penaloza, MD, FACP, AAHIVS, along with Julia Jurkiewicz, MSN, RN-BC, Director of Population Health at Valley Health Partners, believed that the key to helping their patients was to empower their staffs. They decided to examine Appreciative Inquiry (AI)* as a tool for addressing hypertension, and organized a Quality Improvement project around the concept. The project, “Unity, Alignment, and Collaboration: The Success of Appreciative Inquiry to Engage All Team Members in Improving High Blood Pressure for At-Risk Hispanic/Latino Adults in the Primary Care Setting,” spanned three months, from October to December 2019.
The purpose of the project was twofold: First, to demonstrate the effectiveness of the AI model in fueling engagement, positive change, and self-efficacy while implementing interventions to help control patient’s blood pressure. On a universal level, it was intended to improve care quality, efficiency, and the health of the community by achieving better outcomes. The quality metric for hypertension was 77.6% at CDS, just below the threshold of 78.6%. The project staff set their goal at improving the metric by 1% each month, to reach 81.6% by the end of the project.
A basic, reproducible strategy
Appreciative Inquiry asks people to explore strengths and successes that already exist. The premise being that concentrating on the positive leads to higher performance. AI reinforces relationships and culture, creates common vision and direction, promotes learning and innovation, and energizes collective action. The staff at CDS applied this model to patient interaction as well as procedural activities such as closing care gaps. “They were encouraged to identify small actions that could affect change,” says Dr. Penaloza. “We focused on what we were doing the well, and then did more of those things. Plus, we celebrated our successes as a team.”
To ensure follow-through, clinicians were re-educated on proper blood pressure measurement, conducted blood pressure checks for patients whose blood pressure was close to goal, scheduled provider appointments for high risk patients, and ran weekly reports to identify patients whose blood pressure was still not at goal. The staff huddled daily, and connected weekly. These sessions helped sustain a healthy family-oriented culture that embraced change management and inspired ideas and results in a cooperative environment.
Results and patient accountability
In three months’ time, CDS’s Controlling High Blood Pressure metric surpassed the project goal, rising 6.4% to 84%. These outcomes demonstrated that AI, when applied thoughtfully, increases positive emotions and builds the capacity of the staff to promote healthy behavior change. It proved to be a useful tool in the ultimate goal of improving the health and well-being of this most vulnerable patient population.
Dr. Penaloza explains that an important part of the process is patient accountability. He notes that when the staff begins the AI process, they make the expectation clear: that the clinician and patient are a team and have to work together. When the patient achieves success, it is appreciated. They are given a colored bag to use for medication review when they visit the practice. However, Dr. Penaloza points out that the bag is not a gift. “Carrying the colored bag with our LVHN/VHP logo gives patients and their families a sense of belonging to a group of successful people,” he says. “When someone sees a patient carrying it, they know they have earned it.”