Blueprint for Health and 2 more...less...

Blueprint for Health

Blueprint (SISC)

Statewide average % of Blood Pressure in Control


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Notes on Methodology

The statewide average % for the Blood Pressure in Control performance measure was generated by Onpoint Health Data, the statewide administrator of the All-Payer Claims Dataset. Onpoint linked claims in the APCD to clinical records stored by Capitol Health Associates in the Clinical Registry. Onpoint updated this measure every six months, accounting for the next 6-month time period. The statewide average percentage of the Hypertension in Control performance measure was listed in every Health Service Area Adult profile, which can be found here ( The statewide average percentage of the Hypertension in Control performance measure relies on data from the state’s Clinical Registry and therefore is influenced when practices interrupt their data feed to the Clinical Registry. The outcomes described here are estimated using data only from individuals for whom claims data could be linked with valid Clinical Registry data. This non-random sampling variability is not accounted for in the measure


The local Blueprint Transformation Network, which includes: QI Facilitators, Community Health Team leaders, and Program Managers

Staff at Blueprint Patient-Centered Medical Homes

Onpoint Health Data (until 12/31/2019)

Vermont Department of Health

OneCare Vermont

Support and Services at Home (SASH)

New England Quality Innovation Network-Quality Improvement Organization

Community Health Accountable Care, LLC

Vermont Program for Quality in Health Care, Inc.

Story Behind the Curve

The Blood Pressure in Control measure is the fourth of 4 key indicators of quality health care. This measure assesses the percentage of continuously enrolled members with hypertension, ages 18-85 years, whose last recorded systolic blood pressure was less than 140 mm/Hg and whose last recorded diastolic blood pressure was less than 90 mm/Hg.

The Blueprint includes performance-based payments to encourage providers to participate in population and community health improvement initiatives with the goal of greater collaboration. These are key indicators that are in alignment with the All Payer Model core quality measures. Improvements in these areas are indicative of an evolving and improving system of care.

The trend line above suggests an opportunity for improvement given that the data is not moving in the right direction. The Blueprint implemented the pay for performance model on this measure in July 2015. This measure was chosen for payment because it reflected a priority of the provider network (ACOs) in Vermont, it could be generated at the Health Service Area level using Vermont’s centralized data source without any need for additional data collection or reporting by providers, it was tied to prevalent underlying health concerns involving complex medical and social determinants, and it could be improved through better coordination, outreach, and transitions between medical and non-medical providers. The Blueprint for Health, in conjunction with the Vermont Department of Health, OneCare Vermont, SASH, New England QIN-QIO, CHAC, and VPQHC, held a 6-month long peer-learning community to support practices in implementing key strategies to improve blood pressure control in patients with hypertension. In the peer-learning community, we have brought together expert faculty to provide a dynamic learning environment and provided practices the opportunity to learn from peers and have quality improvement.

Last updated:  03/02/2020

  • Continue as a performance measure
  • Support dissemination and use of the OneCare VT toolkit on Hypertension care
  • Deploy QI Facilitators to practices interested in working on QI for hypertension management
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy