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Success Stories

A Little Support Goes a Long Way: Addressing Risk Factors at Sanford Clinic Brookings throughout 1815 Year 3

The likelihood of developing chronic disease and adverse outcomes can be greatly influenced by a variety of circumstances and situations. Sanford Clinic Brookings is working to combat barriers related to several social, environmental, and behavioral risk factors through the use of a screening tool implemented in December 2019. Screenings are given to patients seen in the clinic for well visits or when something within their medical record indicates they could benefit from a screening. When a need is identified through the screening, patients are referred to the on-site social worker, who can assist with finding the appropriate resources to help address the corresponding barrier. Read more

Implementing a Self-Measured Blood Pressure (SMBP) Monitoring Program at Faulkton Area Medical Center

Heart disease remains the leading cause of death worldwide. It’s a concern even small, rural areas in South Dakota cannot escape. To combat high blood pressure within their community, a leading cause of cardiovascular related disease, Faulkton Area Medical Center implemented a self-measured blood pressure (SMBP) monitoring program in March 2021. Following the American Heart Association and American Medical Association’s Target: BP program, Faulkton’s team works with their providers to identify patients who would benefit from additional blood pressure monitoring. Participants are identified through information gathered during clinic visits and/or obtained from their medical records. Individuals meeting program criteria are sent home with a loaner blood pressure cuff or offered a time to bring their home machine to be checked for accuracy. Participants then monitor their blood pressure twice a day for two weeks and return for a follow-up appointment with their provider afterward. At that appointment, participants review the readings with their provider and determine their next steps. If their blood pressure remains elevated at home, participants continue monitoring twice a day while adjusting their medications and/or implementing lifestyle changes. If they are found to either not have hypertension or their hypertension is under control outside the clinic setting, known as white coat hypertension, they continue with their existing treatment plan and return the loaner cuff for use by the next participant. Read more

Huron Clinic Maintains Impressive Blood Pressure Control Rates Through 1815 Year 3

Since February 2019, Huron Clinic has been working with the South Dakota Department of Health (SD DOH) Heart Disease and Stroke Prevention Program (HDSPP) to address increased prevalence of hypertension through a self measured blood pressure (SMBP) monitoring program. SMBP participants are identified either by having an elevated blood pressure (>140/90 mm Hg) in the clinic or having elevated readings or a hypertension diagnosis noted within their medical record. Once participants enroll, they are sent home with a blood pressure cuff to check their readings twice a day for two weeks. After the two weeks, they work with their healthcare team to determine the next steps. If their blood pressure remains elevated at home, the participant will continue to check their blood pressure while implementing prescribed changes to their medication regimen or additional recommended lifestyle changes. This will continue until the participant reaches blood pressure control. If the readings are within the normal range, however, the participant is considered to have white coat hypertension (when an individual has an elevated blood pressure in the clinic setting but is otherwise within normal range). For these individuals, additional treatment is not necessary. Ruling out white coat hypertension before prescribing medication changes reduces the risk of over-prescribing to individuals not needing treatment, which could be dangerous and detrimental to their health. Read more

Huron Clinic Provides Chronic Care Coordination Through 1815 Year 2-3

Huron Clinic has been partnering with the South Dakota Department of Health Heart Disease and Stroke Prevention Program (HDSPP) as part of the 1815 CDC cooperative agreement Implementing Interventions to Improve the Health of South Dakotans through Prevention and Management of Heart Disease, to better address increasing chronic disease rates amongst their population. As part of their efforts, Huron and HDSPP, worked together to implement a new chronic care coordination program in 2020. The Chronic Care Coordinator (CCC) oversees patients with high needs related to multiple chronic conditions, all of which have some form of cardiovascular disease, such as hypertension or high cholesterol, and/or diabetes. The CCC coordinates medical treatment, including 1) administering assessments, 2) developing care plans, 3) monitoring medication compliance, 4) establishing an ongoing relationship with patients, 5) serving as an advocate/champion for patient health, and 6) connecting patients with social and community support systems for continuation of care. All these services have been shown to prevent exasperation of chronic disease and poor health outcomes. Read more

Community-Based Self-Measured Blood Pressure Monitoring Program Using Physical Activity and Lifestyle Modification as the Intervention Piece

When the Mitchell Rec Center applied and received funding for self-measured blood pressure (SMBP) monitoring through the South Dakota Department of Health (SD DOH), they knew they were taking the road less traveled. Some of the goals of an SMBP program are to teach people the proper technique to take their own blood pressure (BP), collect frequent BP readings and ultimately have better blood pressure control. This type of program is traditionally operated in a clinical setting, but this did not stop them. The Mitchell Rec Center saw an opportunity to make a difference in their community and went for it. Participants in their program, Cardio Index, are loaned a blood pressure cuff for two weeks and are asked to check and record 10 blood pressure measurements. Then, the participants receive six weeks of personal training at no charge. After the six weeks, the participants take 10 more blood pressure readings. Read more

Coteau des Prairies Grows Prevention and Management Programming During 1815 Year 3

Coteau des Prairies (CDP) Health Care System has been partnering with the South Dakota Department of Health (SD DOH) Heart Disease and Stroke Prevention Program (HDSPP) team since 2019 to address quality improvement (QI) needs, particularly around their electronic medical record’s (EMR) capabilities. Since the QI work is datadriven, the facility initiated a comprehensive dashboard for easy visualization and analysis of quality measures. Ongoing efforts ensure the dashboard is accessible and data is reviewed for thoroughness and accuracy. Additionally, a method of gathering provider assessment and feedback was established. The team works to streamline the process, available resources, and clinical support and coordination for maximum efficiency and patient benefit. CDP continues to implement SMBP with onboarding providers and clinical staff new to the program. Read more

Improving HPV Vaccination Rates Across Rural South Dakota

In 2019, Horizon Health Care received funding from the SD Department of Health to develop several new strategies to increase Human Papillomavirus (HPV) vaccination rates across its network of 21 medical clinics in South Dakota. Horizon identified an immunization champion, implemented client reminders, provided community education, and developed a dashboard to report HPV vaccination rates for patients age 11-26.

The project was targeted to ensure that Horizon Health Care was able to readily identify their HPV vaccination rates as an organization and follow up with patients who had not received or not completed the immunization series. Read more

Hypertension Management Program: Year 1 Success Story

The Hypertension Management Program (HMP) began as a collaboration between the South Dakota Department of Health (SD DOH) and the Community Pharmacy Enhanced Services Network of South Dakota (CPESN SD). The SD DOH/CPESN SD HMP is a community pharmacy delivered hypertension management program. The goals of the program are to improve patient care access and understanding of their hypertension condition, increase public awareness of uncontrolled hypertension, boost self-monitored blood pressure measurement in South Dakota residents, and improve patients’ quality of life. Finally, an overall goal is to utilize frequent patient communication and close patient relationships with South Dakota community pharmacies to increase collaboration between non-physician health care providers and primary care providers to improve cardiovascular outcomes for South Dakota residents. Read more

Hypertension Management Program Implemented by Local Pharmacies

Cardiovascular disease is the number one cause of death in South Dakota, a chronic illness usually associated with elevated or uncontrolled blood pressure (hypertension). Healthcare systems are continually searching for new and innovative ways to treat their patients in a manner most beneficial and effective for them. This often requires looking to healthcare providers and team members based in the community, who are typically more accessible to the patient.

Read more from the following Pharmacies:
Bien Pharmacy
Brothers Pharmacy
Haisch Pharmacy
Medicine Shoppe
Roger’s Pharmacy
Shane’s Pharmacy

Inspiring Health and Wellness for Patients with Hypertension
at Coteau des Prairies through Compass Care

Coteau des Prairies (CDP) Health Care System partnered with the Department of Health’s (DOH) Heart Disease and Stroke Prevention Program (HDSPP) team in 2019 when HDSPP offered a funding opportunity focusing on quality improvement, team-based care, and implementation and expansion of self-measured blood pressure (SMBP) monitoring. As part of their award, CDP first needed to address their electronic medical record (EMR) capabilities, as much of the work would be data-driven. CDP’s EMR did not initially provide a comprehensive dashboard for easy visualization or analysis of their provider’s quality measures. Once CDP’s EMR provider dashboard was accessible, data needed to be reviewed for thoroughness and accuracy, an ongoing aspect of quality improvement. After establishing baseline data, clinical support and coordination of patient care across the health care team had to be streamlined for maximum efficiency and patient benefit. Lastly, CDP needed to implement SMBP, a new program to the facility. All these initiatives required staff and patient buy-in, training, and development of new workflows, policies, and processes. Read more

Huron Clinic’s Self-Measured Blood Pressure Monitoring Program Proves an Effective Model for Hypertension Diagnosis and Control

Cardiovascular disease is the leading cause of death in South Dakota with hypertension being a primary risk factor. The growing elderly and sedentary population as well as unique challenges facing SD’s rural and frontier communities have created a need for new prevention and management methods directed toward cardiovascular health. In February 2019, Huron Clinic partnered with South Dakota Department of Health’s Heart Disease and Stroke Prevention Program (HDSPP) to develop and implement a self-measured blood pressure (SMBP) monitoring program. The clinic established several goals at the start of the process. First, they wanted to achieve and maintain a baseline NQF 18 rate of 80%. At the time of program development, Huron Clinic’s rate was 67%, meaning of the patients in their facility diagnosed with hypertension, 67% were considered to have their blood pressure under control, or measuring below 140/90 mmHg. One of the first steps to hitting their 80% goal was thoroughly reviewing their performance measure data and ensuring they were starting with accurate and reliable information. It was discovered that several issues within the electronic medical record (EMR) were skewing their data. For example, when an individual had an initial elevated blood pressure check during their office visit but a reading that was within normal limits upon re-check, the EMR would pull the out-of-range reading into the performance measure instead of using the controlled reading as it should. This caused their NQF 18 rate to appear worse than it actually was. As this was a known EMR issue, the EMR vendor had to develop a program update to correct the problem. In the meantime, Huron Clinic manually reviewed and updated measurement readings so their NQF 18 would accurately reflect their true blood pressure control rate. In addition to meeting their performance measure goals, Huron Clinic planned to assess “white coat hypertension” within their patient population, a term used to describe when one has an elevated blood pressure in the clinic setting but an otherwise normal reading. Ruling out white coat hypertension before prescribing medication therapy changes would reduce the risk of over-prescribing to individuals not needing treatment which could then be dangerous and detrimental to their health. Additionally, SMBP would provide an excellent opportunity to closely monitor patients with hypertension and adjust medication dosing to find the best and most appropriate treatment plan. This also gave providers a better understanding of their patient’s day-to-day blood pressure levels and allowed them to closely work together to set realistic blood pressure goals.
*members of the SMBP team included representatives from Huron Clinic, HDSPP, Dakota State University – Centers for Advancement of Health IT, and Great Plains Quality Innovation Network. Read more

Overcoming Barriers Around Social Determinants of Health

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. They affect a wide range of health risks and outcomes. South Dakota is not immune to negative outcomes based on SDOH, so Sanford Clinic Brookings sought a way to better assist their patients with overcoming barriers to social determinants of health. Read more

South Dakota Opioid Program Campaign Goes “Viral”

The South Dakota Opioid Abuse Program has successfully expanded their brand recognition, reached a large portion of the general public with their messaging, and received positive feedback from stakeholders and legislators about their media efforts. Read more

Increasing Healthcare Referrals for Better Choices, Better Health® South Dakota

Developing a sustainable system for Better Choices, Better Health® South Dakota (BCBH-SD) referrals has helped to form clinical-community linkages with our healthcare systems. This process allows providers to support their patients by providing resources that help them become more confident about their role in condition management and improved quality of life. Read more

Hypertension Management Program in Community Based Pharmacy Prevents Potential Cerebrovascular Event

A patient presented to the Medicine Shoppe for an initial consult to determine eligibility for the pharmacy’s newly launched Hypertension Management Program (HMP). Multiple in-store readings showed her blood pressure at 168/104, well above a safe or healthy blood pressure range. Read more

Supporting Cancer Patients and Survivors Through Implementation of Evidence-Based Nutrition Interventions

Project efforts included implementation of an evidence-based nutritional screening tool, best practice alert, and nutrition services within a cancer treatment center located in Sioux Falls, SD. The cancer treatment center increased system changes and provision of nutritional services for cancer patients and survivors through project implementation. Read more

Preventing Cancer in South Dakota: Successful Strategies to Increase HPV Vaccination Rates

The South Dakota Comprehensive Cancer Control Program (SDCCCP) partnered with health systems across South Dakota to increase the state’s human papillomavirus (HPV) vaccination rates. Efforts focused on the implementation of evidence-based interventions. Increases in first dose initiation and series completion rates were seen among all participating sites. Read more

Finding Innovative Ways to Increase Colorectal Cancer Screening: The Best Test is the One That Gets Done

Sanford Health chose a clinic from each region to pilot a project intended to improve colorectal cancer screening rates. The clinics received 100 Fecal Immunochemical Tests (FIT) to mail to patients who were
past due for colorectal cancer screening and were clinically appropriate for the FIT test. Beyond the basic parameters, the clinics were then allowed to create their own processes for identifying patients and reaching out to them. The minimum expectation was to track how many FITs were sent out, how many were completed, the results and any positives be followed up with a colonoscopy. Read more

Utilizing Evidence-Based Interventions to Increase Preventative Cancer Screening Among the Hutterite Population in SD

Preventative cancer screening rates for the SD Hutterite population insured by DAKOTACARE are disproportionately lower than screening rates of the overall SD population insured by DAKOTACARE. During project implementation, a challenge encountered by the DAKOTACARE team involved additional time and effort required to manage the procedural differences regarding scheduling, billing, and coordination of three different Avera mobile mammography units located in Sioux Falls, Mitchell, and Aberdeen. Read more

Falls Community Health Partners with Local Clinic to Provide Colonoscopies at Reduced Rate

Falls Community Health (FCH) is a Federally Qualified Health Center that has joined the march to a nationwide colorectal cancer (CRC) screening rate of 80%. FCH serves all patients, but many of its patients are either underinsured or uninsured. There are close to 1,880 patients between the ages of 50 – 75, the recommended screening age for colorectal cancer. Read more

Funding Opportunity Assists in Increasing Colorectal Cancer Screening Rates

The South Dakota Comprehensive Cancer Control Program awarded grants to four healthcare organizations to support the implementation of evidence-based interventions focused on increasing colorectal cancer screening rates. Grantees were chosen from various geographic locations across the state, including medically underserved areas. Read more

South Dakota’s Successful Implementation of the National Diabetes Prevention Program

Over 200,000 South Dakotans have prediabetes, a condition that increases their risk of developing type 2 diabetes. As the incidence continues to rise, South Dakotans are taking steps to prevent type 2 diabetes by participating in the National Diabetes Prevention Program. Read more

Survivorship: Putting the Pieces Together

Avera Cancer Institute Mitchell’s successes and lessons learned from providing an online, interactive platform for cancer survivors to access information about survivorship such as nutrition, advance care planning, advance directives, physical activities, and connect with other SD cancer survivors for peer support. Read more

Teaming Up to Bring Palliative and End of Life Care Education to Rural Interprofessionals

LifeCircle SD, a statewide collaboration of institutions, organizations and people committed to improving end-of-life care, collaborated during a nine month period to plan, develop and implement a day-long workshop for palliative and end of life training for healthcare professionals in Winner, SD. Read more

Before It’s Too Late

A 64 year old, unemployed man received early colorectal screening, education, and follow up thanks to SD CCCP Colorectal Workgroup’s pilot project. Typically, low-income people don’t receive this type of care until it’s too late. Read more