Table 3 Overview of activities by visit for the 12-month PF intervention

Web-based “kick-off” learning session

● Each wave of practices attends a virtual meeting to review the purpose of the study, the evaluation plan (e.g. surveys), and discuss team-based care and the application to improving HTN management and outcomes

Getting Started Part 1 (Visit 1)

● Provide overview of the principles of TBC, the five HTN strategies, and an explanation of the benefits of TBC for HTN management

● Meet with team members to assess roles and responsibilities and conduct PCTGA needs assessment

● Meet with practice staff to assess general roles and responsibilities

Getting Started Part 2 (Visit 2)

● Introduce how SIPs can implement the HTN strategies using TBC

● Explore potential challenges to using TBC to implement the HTN strategies in a small practice

● Review the practice’s BP control rate

● Introduce and define the concept of QI

● Set expectations for working on this QI project

● Help establish routine communication channels among the team

● Introduce Root Cause Analysis (RCA)

● Lead the practice care team through an RCA exercise

HTN Strategies 1—5

● Obtain and review monthly HTN control rate and any other relevant quality measure specific for the strategy

● Review/Discuss the relevance and importance for supporting the strategy

● Conduct workflow mapping of how the practice currently implements the strategy

● Assess barriers to implementing the strategy

● Conduct an RCA of identified barriers to implementing the strategy

● Assess whether the EHR is set-up to support to support the strategy

● Help set-up the EHR to support the strategy (if necessary)

● Determine if the practice care team is appropriately using the EHR to support the strategy

● Determine training needs to support the strategy

● Describe/review/provide trainings for the best practices for implementing the strategy

● Discuss how TBC elements can be integrated into the workflow to support the strategy

● Agree on a clear shared practice goal for the strategy

● Support the practice care team to develop a new workflow

● Support the practice care team to implement an PDSA cycle to integrate new workflow and assess practice goal (outcome)

● Evaluate the PDSA cycle and revise workflow as needed

Wrap up

● Review the 6-month BP control rate

● Review the 6-month race/ethnicity documentation rate

● Conduct the PCTGA

● List gains the practice care team has made

● Confirm which new workflows the practice care team will sustain after the project

● Establish actionable steps the practice care team can take to continue improvements and sustain gains

● Confirm which established routine communication channels the team will continue to use to enable sustainability

● Complete the HTN Management Checklist