Alaska: Cross-Agency Collaboration to Control Hypertension
State Spotlight | November 2022
The Centers for Disease Control and Prevention’s (CDC) 6|18 Initiative highlights CDC and partners targeting six common and costly health conditions with 18 proven interventions. The following example from Alaska showcases some of the strategies used to address one condition under the 6|18 Initiative. These profiles are stories reported by the state officials based on their work within the 6|18 Initiative.
Alaska Key Facts
- State population: 732,673
- Medicaid population: 252,090
- Medicaid enrollees in fee-for- service: 100 percent
Under the Centers for Disease Control and Prevention’s (CDC) 6|18 Initiative, Alaska’s Medicaid agency, administered by the Division of
Health Care Services (DHCS), and public health agency, the Division of Public Health (DPH), partnered to address hypertension in the state. The agencies are independent of one another, though both divisions are housed within the Alaska Department of Health and Social Services (DHSS).
Alaska’s Medicaid and public health agencies partnered to implement a prevention project focused on:
- Promoting strategies that improve access and adherence to anti-hypertensive and lipid-lowering medications; and
- Promoting a team-based approach to hypertension control (e.g., physician, pharmacist, lay health worker, and patient teams).
Alaska’s DHCS/DPH Accomplishments Related to 6|18 Priorities
- Extended the refill period for all 90-day prescriptions from seven days to 21 days.
- Expanded a community health worker program to support hypertension control in rural communities.
- Increased access to blood pressure monitors in rural communities.
- Allowed pharmacists to bill for hypertension-related counseling and medication management therapy.
Alaska’s DHCS/DPH 6|18 Project Activities
Alaska extended the refill period for all 90-day prescriptions from seven days to 21 days. In remote areas of the state, such as the Aleutian Islands, supply chain interruptions due to delays in the postal service are common. This supply chain issue can cause some patients to exhaust their medication supply before the refill supply arrives — expanding the refill period to 21 days adds a buffer to delivery challenges. DHCS had already been considering how to change the policy for some time but had not yet acted. Through the 6|18 collaboration, DPH was able to speak directly with the state-level Medicaid pharmacist on the team about the importance of the issue and accelerate the timeline of the policy change. This policy change was of particular significance to patients with high blood pressure medication regimens but may improve medication adherence for other conditions as well.
All community health workers (CHWs) working with the Providence Alaska Community Partnerships Program are trained in the Healthy Heart Ambassador (HHA) Blood Pressure Self-Monitoring program (HHA-BPSM) The program has been tailored slightly to fit the goals of the CHW team to meet with their participants one-on-one in their homes to overcome barriers to access. Technical assistance was provided by Alaska’s Heart Disease and Stroke Prevention program
staff to support community-based organizations in setting up necessary policies, procedures, and program workflows to outline and implement this program. CHWs enrolled in the Alaska Primary Care Association (APCA) program were provided with training and referral tools on how to measure blood pressures as well as tools to refer to digital or in-person self- monitored blood pressure (SMBP) programs. All CHWs are invited to participate in Alaska’s SMBP community of learning space, which is a forum where SMBP programs from across the state meet to discuss barriers and brainstorm solutions.
CHWs working for other community agencies, such as the Pacific Islands Communities of Alaska and the Alaska Black Caucus, have reached out to Alaska’s DPH and DHCS to discuss the possibility of setting up their own SMBP programs as well as ways to disseminate information to communities about low or no cost risk reduction programs, including the SMBP programs.
Alaska’s Heart Disease and Stroke Prevention program was also able to secure a supply of automatic blood pressure machines that are available to all SMBP programs at no cost to support the start-up costs associated with an SMBP program. Further, the State of Alaska Chronic Disease Prevention and Health Promotion (CDPHP) team hosts the only two HHA-BPSM trainers who provide the HHA-BPSM program curriculum and training to any interested program facilitators at no cost.
Alaska’s Medicaid and Public Health team focused on ensuring that individuals living in rural areas throughout the state, including in the Eastern Aleutian Tribes, had improved access to devices for self-measured blood pressure. The Medicaid- public health team explored the possibilities of establishing remote blood pressure monitoring in community settings through their joint efforts. While remote blood pressure monitoring was not established, Alaska was able to proceed with complementary efforts to increase access to blood pressure monitors. Specifically, Alaska’s Heart Disease and Stroke Prevention (HDSP) program maintains a collaborative relationship with the American Heart Association (AHA), which offers technical assistance to many SMBP across the state. Nearly all SMBP programs in the state that are receiving Health Resources and Services Administration (HRSA) grant funding are utilizing AHA SMBP program curriculum and receiving technical assistance from AHA. This HRSA grant supports SMBP programs at federally qualified health centers across the state. Alaska’s Department of Health and Social Services (DHSS) offers resource referrals and additional technical assistance to community partners and health organizations. Some federally qualified health organizations received funding from HRSA to address hypertension. Programs not covered under this HRSA grant may also work with Alaska HDSP to secure a supply of blood pressure cuffs to be used for program start-up and, if desired, a blood pressure cuff loaner program. Alaska DHSS was also able to secure a supply of automatic blood pressure machines that are available to all SMBP programs at no-cost to help support the startup costs associated with an SMBP program. Finally, Alaska’s Chronic Disease Prevention and Health Promotion (CDPHP) team hosts the only two HHA-BPSM trainers, who provide the HHA curriculum and training to any interested program coordinators at no cost. The HDSP program facilitates a monthly SMBP community of learning forum that gathers SMBP programs of all types together to discuss projects, programs, and barriers, and brainstorm solutions. This community of learning comprises SMBP programs of all types, both those under the HRSA grant, those run by CHWs, programs delivered at clinic-based wellness programs, and even community-based programs not in clinical settings. The monthly SMBP community of learning consists of urban and rural locations in order to facilitate a peer-to-peer approach to address barriers identified.
In addition to these efforts, a digital SMBP program is available through Alaska’s Omada for Prevention program at no cost to all Alaskans. Alaskan’s who enroll in this program are given a Bluetooth blood pressure monitor that syncs with the app for ease of use and tracking. Alaska officials reported that these efforts throughout the state, including in Alaska’s rural regions, contributed to increased access to blood pressure monitors.
Alaska’s Medicaid and Public Health team was interested in improving pharmacist reimbursement for hypertension-related counseling and medication services and engaged in discussions about a list of best practices with the Pharmacist Association. One of the team’s near-term goals included working across divisions to synchronize medications to reduce the number of times individuals need to visit the pharmacy to pick up their medications.
Further, Alaska’s Medicaid and Public Health team shared that they worked to ensure that pharmacists were able to bill for hypertension-related counseling and medication management therapy. Pharmacists specialize in medication management and are the most accessible health care providers in rural communities. Chronic diseases, such as diabetes and cardiovascular disease, are leading causes of death and disability among Alaska residents. Research indicates that chronic disease risk from diabetes and cardiovascular disease can be reduced through pharmacist-provided health service management. Pharmacists needed training to understand how they could impact diabetes and cardiovascular management health services in rural communities. They also did not understand how to properly bill payers. To address this unmet need identified during the 6|18 Initiative, the Alaska Pharmacist Association sponsored the Sustainable Education & Training Model under the Pharmacist Provider Reimbursement (SETMuPP) demonstration project funded in part through a non-competitive, CDC, state investment grant.
Coordination between DPH was improved through regular team meetings and the development of a joint project work plan toward aligned goals. Previously, DPH and DHCS would each work toward their own goals and sometimes result in inconsistencies in the priorities presented to outside engaged partners. These inconsistencies would then sometimes hinder existing work as the divisions managed the conflicting messages. DPH and DHCS now work in conjunction, with both divisions identifying what they can focus on together rather than working at cross-purposes. DPH and DHCS report that all of Alaska’s 6|18 policy achievements are related to this innovative collaboration and is a good indicator of the long-term sustainability of cross sector collaboration in the state.
The Alaska team also took steps to improve communication with other state agencies, even beyond DPH and DHCS, when it became apparent that these relationships required strengthening. For example, in trying to improve the supply of blood pressure medication to remote regions of the state, the state hypertension program spent a significant amount of time looking into how tribal health facilities could make use of the federal 340B program. The hypertension program would later discover and report that many tribal health facilities had already explored this option and had chosen to terminate their participation because they felt that cost savings were not enough to offset the administrative burdens.
This publication was supported by the Centers for Disease Control and Prevention (CDC) contract #47QRAA20D001M, awarded to the National Opinion Research Center (NORC) in partnership with the Center for Health Care Strategies (CHCS). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
CDC would like to thank Cheley Grigsby, Health System Collaboration Unit Manager, Chronic Disease Prevention and Health Promotion, Alaska Department of Health, NORC and CHCS for their significant contributions to the 6|18 series of profiles with public health innovators across the United States. Please contact 618@chcs.org with any questions.