Chronic Conditions - Key Activity 11


Screen for Chronic Conditions


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; address social needs.


Standard screening for chronic conditions reduces morbidity and mortality by detecting disease at an earlier stage, which in turn ensures that clinical management can begin closer to onset. If a patient is diagnosed as prediabetic or has elevated blood pressure, interventions in the form of lifestyle changes can be implemented to help reverse the diagnosis. This activity provides guidance on how to incorporate standardized blood pressure screening protocols and diabetes management protocols into your clinical workflows.

Screening for diabetes and hypertension is important because:

  • Early detection and treatment can prevent or delay the onset of serious complications from diabetes and hypertension.
  • Effective management of diabetes and hypertension has the potential to reduce the likelihood of adverse outcomes in the future.

Implementing a universal screening process reduces barriers to care by facilitating a process in which people are screened in a manner that promotes equity. Risks related to diabetes and hypertension differ by population. Therefore, having a standard process is crucial to fitting the needs of various populations. It is recommended that for the purposes of hypertension, a blood pressure screening occurs at every visit.

Diabetes and hypertension are conditions that are more difficult to manage and are affected by the social needs of patients. Therefore, systematically assessing social needs and other factors that influence patients’ ability to achieve diabetes and hypertension control (e.g., access to a refrigerator, access to safe places to exercise, access to healthy foods, etc.) is important. By acknowledging and working within the social needs of patients, clinicians can work collaboratively with the patient to make lifestyle and medication adjustments that are tailored to their needs.

Relevant HIT capabilities to support this activity include care guidelines with a specific focus on recommended screenings, clinical decision support and PVP tools.

(See Appendix E: Guidance on Technological Interventions.)

By leveraging PVP strategies, available embedded clinical decision support and screening guidelines, care teams can plan for chronic disease screening. Use of standing orders can support these efforts.

Action steps and roles

1. Utilize appropriate recommendations for screening.

Suggested team member(s) responsible: medical director (or equivalent) and QI officer.

See the ADA recommendations for diabetes screening.

For hypertension, accurate blood pressure measurement should be completed at every visit. Each care team should be provided adequate equipment for screening, including validated, automated monitors and an adequate supply of all blood pressure cuff sizes. The AHA also has resources available that outline protocols for correct blood pressure measurement.



2. Utilize clinic data to identify any patients who have not been officially identified in their respective registries.

Suggested team member(s) responsible: EHR specialist (or equivalent), QI officer and medical director (or equivalent).

Systems should establish mechanisms for identifying hypertensive and diabetic patients who meet criteria for a respective diagnosis but have not yet been officially identified in their chart documents or have never had their blood pressure taken. This might occur when blood pressure is not tracked over time or when blood pressure is taken incorrectly. More information is provided in the National Association of Community Health Centers’ Hiding in Plain Sight Change Package.


3. Integrate screening criteria into clinical workflows.

Suggested team member(s) responsible: QI officer, nursing officer (or equivalent), and nursing or MA staff.

These workflows may include, but are not limited to, the pre-visit planning process and standing orders. A blood pressure measurement protocol should be established. It is recommended that blood pressure is taken at every visit. See Key Activity 10: Develop or Refine and Implement a Pre-Visit Planning Process and Key Activity 9: Develop and Implement Standing Orders for more information.


4. Evaluate patients further as needed, with appropriate lab work.

Suggested team member(s) responsible: clinicians and medical support team.

Lab work may be appropriate for hypertension after a diagnosis is confirmed to further evaluate secondary causes. For diabetes management, another A1c or fasting blood sugar test might help confirm the diagnosis. Urine microalbumin can help assess for complications.

Chapa-De Indian Health’s diabetes protocols, which address retinal screening, provide an example of the need for further evaluation. The vast majority of patients who develop diabetic retinopathy have no symptoms until the very late stages (by which time it may be too late for effective treatment); this emphasizes the importance of regular evaluation. Additionally, this resource from Alexander Valley Healthcare provides information on workflows and promising practices in diabetic retinal eye exam screening.

The following guidelines should be utilized for the evaluation and treatment of hypertension:

  • Establish new diagnosis of hypertension per guideline (two office-based readings >140/90) with confirmation by home readings (>135/85).
  • Order baseline tests for new diagnoses of hypertension, including but not limited to the following:
    • Complete blood count.
    • Electrolytes.
    • Creatinine with eGFR.
    • Lipids.
    • Thyroid stimulating hormone (TSH).
    • A1c.
    • Urine albumin-to-creatinine ratio.
    • Urinalysis.
    • EKG.
  • Follow established hypertension guideline for blood pressure goals, including home readings (HEDIS, ACC/AHA, Kaiser Permanente).
  • Follow preferred medication protocol using fixed-dose combination (FDC) for initiation and titration.
  • Utilize team-based care for titration. The team may include a pharmacist, a nurse practitioner/physician assistant, or a nurse.


5. Consider referrals to specialists to assist with further tailoring care plans.

Suggested team member(s) responsible: clinicians and medical support team.

Examples of potential resources to refer patients to include but are not limited to:

  • A health coach or behavioral health specialist: They can work with patients to further evaluate any behavioral health screening concerns. Another asset of behavioral health interventions is assisting the patient with developing a plan for manageable lifestyle changes, which can help them best manage the disease. An overview of how this can be accomplished is from Cherokee Health Systems, which uses an integrated behavioral health approach to address a variety of behavioral health concerns.
  • A clinical pharmacist or other care team members (if appropriate) who can assist with titration for antihypertensives/hypoglycemics.

Implementation tips

  • Consider ongoing quality improvement projects that are linked to correct measurement of blood pressure This may include an unobserved or observed audit, or other process measures, such as repeating a blood pressure when necessary.
  • Antidepressant use has been linked to the development of new onset diabetes, particularly with long-term use or higher dosages. It is especially important to screen people with behavioral health conditions for chronic disease.

National Association of Community Health Centers’ Hiding in Plain Sight Change Package

This change package is a deliverable of the National Association of Community Health Centers’ Million Hearts Hiding in Plain Sight project. It was produced by reviewing the details of the change ideas each health center team employed and any associated tools and resources. This document is a compilation of items thought to be most valuable and to most clearly capture the best that emerged from this work. The change package structure and organization align with the clinical decision support/QI worksheets used to map and identify enhancements to workflows around identifying potential undiagnosed hypertension, engaging patients in care and diagnosing hypertension in a timely and accurate manner. These three steps are critical precursors to managing hypertension successfully and achieving blood pressure control. This change package also aligns with the Centers for Disease Control and Prevention/Million Hearts’ Hypertension Control Change Package.

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