Team-supported, EHR-leveraged, Active Management for Hypertension (TEAM)

Last updated 2024-03-08T16:41:32Z

TEAM is a proven evidenced-based, adaptable, effective, economically sustainable, and telehealth-delivered Quality Improvement program that improves cardiovascular disease of all Veterans, particularly among underrepresented and underserved minorities, rural, and Women Veterans, through the use and adaptation of existing VA tools and resources. TEAM's implementation, adaptations, and linkages to effective VA resources achieves improved blood pressure control while simultaneously reducing barriers to care and increases Veteran engagement with the VA healthcare system. TEAM addresses critical gaps and considerations in translating research to practice and is considered a model program with successful implementation and outcomes in more than 16+ sites nationally that has now served over 900 Veterans. Recently, we have developed a specific track for women (TEAM-WV) to address heart disease risk unique to women.

Origin:

October 2018, Durham VA Medical Center

Adoptions:

9 successful, 7 in-progress

Partners:

Health Services Research & Development, Office of Rural Health

Overview

The problem

Despite well-established, evidence-based therapies to treat hypertension, many patients fail to reach target blood pressure goals. Common patient barriers to achieving optimal blood pressure control include competing demands and not knowing how to focus their effort. Barriers for clinical teams include busy clinical demands and lack of tools to comprehensive ... Despite well-established, evidence-based therapies to treat hypertension, many patients fail to reach target blood pressure goals. Common patient barriers to achieving optimal blood pressure control include competing demands and not knowing how to focus their effort. Barriers for clinical teams include busy clinical demands and lack of tools to comprehensively assess patient-specific risk factors. Population level barriers include failure to make use available population data to target efforts to those at greatest risk. The COVID-19 pandemic amplified and added to these barriers leading to a worsening of hypertension control for many Veterans.

TEAM was designed as a virtually-delivered program to reduce CVD risk among rural veterans, specifically by improving blood pressure control. TEAM features core components to address the barriers to blood pressure control at the patient, clinical team, and population levels. In addition TEAM can be readily adapted to facility and clinic level patient characteristics (e.g. gender, race/ethnicity) and clinic resources (e.g. specific consults or local tools available) to significantly reduce CVD complications for Veterans. See more

The solution

TEAM is an evidence-based, population-focused, virtually-delivered initiative that addresses patient, clinic, and population level barriers to optimal blood pressure control. TEAM can be adapted to address the unique health demands and care preferences of VHA prioritized populations such as minorities, Women Veterans and rural Veterans. TEAM's overarching g ... TEAM is an evidence-based, population-focused, virtually-delivered initiative that addresses patient, clinic, and population level barriers to optimal blood pressure control. TEAM can be adapted to address the unique health demands and care preferences of VHA prioritized populations such as minorities, Women Veterans and rural Veterans. TEAM's overarching goal of reducing CVD risk is achieved through improved blood pressure control and linkage to VA and community-based resources. See more

Files

Adaptable to YOUR VA! TEAM Brochure for Patients!

The results

Results obtained from blood pressure values at 45, 90, and 180-day intervals as operationalized by the CVD HEDIS measures at implementing sites demonstrates an average change in Systolic blood pressure from 14-24mmHg and Diastolic Blood Pressure from 8-9mmHg. Implementation outcomes including engagement, adaptions, consults, clinical outcomes and toolbox are ... Results obtained from blood pressure values at 45, 90, and 180-day intervals as operationalized by the CVD HEDIS measures at implementing sites demonstrates an average change in Systolic blood pressure from 14-24mmHg and Diastolic Blood Pressure from 8-9mmHg. Implementation outcomes including engagement, adaptions, consults, clinical outcomes and toolbox are disseminated to all participating sites and community based outpatient clinics. See more

Diffusion tracker

Does not include Clinical Resource Hubs (CRH)

NC: Charles George Department of Veterans Affairs Medical Center (Asheville)

Started adoption on 06/2021.

NC: Franklin VA Clinic (Franklin, North Carolina)

Started adoption on 07/2021.

NC: Greenville VA Clinic (Greenville, North Carolina)

Started adoption on 08/2021.

NC: Hickory VA Clinic (Hickory)

Started adoption on 08/2021.

NC: Kernersville VA Clinic (Kernersville)

Started adoption on 10/2019.

NC: North Charlotte VA Clinic (North Charlotte)

Started adoption on 07/2021.

NC: Rutherford County VA Clinic (Rutherford County)

Started adoption on 06/2021.

NC: W.G. (Bill) Hefner Salisbury Department of Veterans Affairs Medical Center (Salisbury)

Started adoption on 10/2019.

NY: Syracuse VA Medical Center (Syracuse)

Started adoption on 02/2021.

CA: Sepulveda VA Medical Center (Sepulveda) NY: Auburn VA Clinic (Auburn)

Started adoption on 09/2021.

NY: Binghamton VA Clinic (Binghamton)

Started adoption on 08/2021.

NY: Donald J. Mitchell Department of Veterans Affairs Outpatient Clinic (Rome, New York)

Started adoption on 09/2021.

NY: Oswego VA Clinic (Oswego)

Started adoption on 09/2021.

NY: Watertown 2 VA Clinic (Watertown 2)

Started adoption on 09/2021.

NY: Watertown VA Clinic (Watertown, New York)

Started adoption on 09/2021.

There are no unsuccessful adoptions for this innovation.

Multimedia

Videos

Above:

Hear from TEAM members.

Implementation

Departments

Nursing services
Complementary and alternative medicine
Whole health
Women Veteran care
Telehealth
Advice nurse
Cardiology
Diabetes
MOVE! weight management
Physical therapy, occupational therapy and kinesiothology
Primary care
Rehabilitation and prosthetics
Recreation and creative arts therapy
Pharmacy

Core Resources

Resource type	Resource description
PEOPLE	Clinical Application Coordinator- ~.05FTE Population Health Manager- ~.25 FTE

Support Resources

Links

Use this resource to create and print your own assessment. Create Your Own Assessment!

Contact

Comment

Comments and replies are disabled for retired innovations and non-VA users.

Email

Email VHADURTEAM-HSRD@va.gov with questions about this innovation.

About

Origin story

TEAM grew out of decades of intervention development and evaluation to address the cardiovascular risk of Veterans, especially those at greater risk combined with direct patient care experience of trying to engage and effect change with individual patients diagnosed with high blood pressure. The opportunity arrived to focus this experience into a new program ... TEAM grew out of decades of intervention development and evaluation to address the cardiovascular risk of Veterans, especially those at greater risk combined with direct patient care experience of trying to engage and effect change with individual patients diagnosed with high blood pressure. The opportunity arrived to focus this experience into a new program (TEAM for hypertension) with funding from the Office of Rural Health. We started the program through a collaboration with the primary care clinic at the Greenville, NC HCC. We made iterative adjustments to TEAM based on their feedback and then expanded to additional sites. During the early COVID-19 pandemic, our program proved to be a good fit for primary care clinics struggling to maintain control of chronic diseases for patients remotely during this crisis. We have since continued to expand to new sites and have developed a strong network of TEAM population health managers who keep the program dynamic and growing.

Original team

Hayden B. Bosworth, PhD

Principal Investigator

Karen Goldstein, MD

Co Principal Investigator

Search categories

Access to Care Age-Friendly Continuity of Care Coordinated Care COVID-19 Diversity, Equity, and Inclusion Healthcare Administration Health Equity Primary Care Rural Health

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