High Blood Pressure

Quality Improvement

Team Based Care

Fact Sheets


Home Blood Pressure Monitoring

Standardized HTN Treatment protocols
(including the customizable template)

NY Health Dept. Diabetes Prevention and Management Toolkit

Self-Measured Blood Pressure Monitoring-Action Steps for Public Health Practitioners

Million Hearts® Blood Pressure Tool Kit

Health Information Technology

Million Hearts®

Quality Improvement

Making Connections

Primary Care Association
Find your state's Primary Care Association

Quality Improvement Organization
Connect with your local CMS Quality Improvement Organization (QIO)

CMS Innovation Center
Learn more about your states participation in various health care initiatives by visiting the Center for Medicare & Medicaid Services Innovation Center. There you can search by state for "Where Innovation is Happening"

Model for Improvement

Quality Improvement Principles

  • Listen to customers (patients)
  • Tap into the people within the system
  • Understand processes and interactions within the system
  • Measure to learn and understand variation
  • Test on a small scale to test change ideas

Model for Improvement & Plan Do Study Act
The Model for Improvement is a framework used by many to guide improvement work. The Model for Improvement, developed by Associates in Process Improvement, is a simple, yet powerful tool for accelerating improvement.

The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change - by planning it, trying it, observing the results, and acting on what is learned.

To learn more about MFI & PDSA visit: Institute for Healthcare Improvement

Example using the Model for Improvement and PDSA for improving the detection of high blood pressure

Practice Facilitation

Practice facilitation, sometimes also referred to as quality improvement coaching, is an approach to supporting improvement in primary care practices that focuses on building organizational capacity for continuous improvement (Knox, 2010).

Practice facilitators (also known as practice coaches, QI coaches, and practice enhancement assistants) are specially trained individuals who work with primary care practices "to make meaningful changes designed to improve patients' outcomes. They help physicians and quality improvement teams develop the skills they need to adapt clinical evidence to the specific circumstance of their practice environment" (DeWalt, et al., 2010).

Practice facilitators can play a key role in helping practices to implement team-based care by assisting with the set-up of care teams, redesigning workflows, clarifying each team member's role, and establishing more effective means of communication to strengthen team approaches to care. The Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers provides exercises that practice facilitators can use to increase practice staffs' understanding of how using a team-based model to spread workloads and shift responsibilities benefits both care team members and patients.

For more information on how to help primary care practices use team-based care to improve the delivery of care, see Module 19 of The Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers. You can download a PDF copy of the entire handbook free of charge at the PCPF Resources page of AHRQ's PCMH Resource Center

Team Based Care

A Program Guide for Public Health, Partnering with Pharmacists in the Prevention and Control of Chronic Disease

Partnering with Pharmacists in the Prevention and Control of Chronic Diseases, CDC

Primary care and Public Health Initiative, CDC, Dec 2013

Team Up. Pressure Down a CDC nationwide program in partnership with the Million Hearts® initiative, to lower blood pressure and prevent hypertension through pharmacist-patient engagement. Visit: Million Hearts

Engaging Pharmacists - Presentations from 1305 Grantee Meeting September 2014
Engaging Pharmacists in State Public Health Actions, Lori E. Hall, PharmD - CDC Division of Diabetes Translation

Utah Department of Health, N. Bissonette, Utah Projects Involving Pharmacists

Montana Department of Health, C. Oser, Community Pharmacy Assessment and Montana Team Up. Pressure Down. Community Pharmacy Projects

TeamSTEPPS. The Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense have developed TeamSTEPPS, a training curriculum designed to improve patient safety, communication, and teamwork skills within a health care organization. The TeamSTEPPS curriculum and accompanying materials support practice efforts to provide higher quality patient care by creating highly effective health care teams. By implementing the TeamSTEPPS program, teams can clarify roles and responsibilities and improve communication and leadership capacity to optimize the sharing of information and resources, which ultimately helps health care professionals to establish and sustain a culture that promotes quality and safety within their organizations.
The Primary Care version of TeamSTEPPS specifically addresses the challenges and opportunities of primary care, office-based teams. For more information on primary care TeamSTEPPS visit: AHRQ

Community Health Worker

Guide for States Implementing Community Health Worker Strategies
This technical assistance guide summarizes the successful work of organizations as it relates to Domains 3 and 4 (Health Systems Interventions and Community-Clinical Linkages, respectively) of CDC's State Public Health Actions Program (CDC-RFA-DP13-1305). It also offers insights for states that are implementing Community Health Worker (CHW) strategies

The National Association of Chronic Disease Directors has developed an activities database that captures initiatives that the state departments of health are engaged in related to blood pressure. For states that are not sure where to begin to work on Million Hearts® activities related to blood pressure, this is a helpful place to start. Activities currently in the database can be searched by state or by more specific criteria, such as the type of initiative (e.g., quality improvement, pharmacist, self-measurement of blood pressure). Contact information for the person who submitted the activity is included, so others may contact them for more detailed information. The database is currently being expanded to include activities and success stories related to other chronic conditions.