Guideline title: Blood Pressure Control
Publication Status: Active
Date of publication:
Date of last evidence search:
Scope:
Methods: Current guidelines and literature review and expert consensus
Description:
Chronic Disease Management
Blood Pressure Control - Coming Soon!
The checklist tool translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.
Ambulatory Care Setting
Health Care Professional Checklists
Resources and Tools
To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)
To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.
Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.
Primary Care Settings and Professionals
Primary Care Settings and Professionals Score Cards
Hospitals
Hospital Score Card
Dental Clinics and Dentists
Dental Clinics and Dentists Score Card
Community Pharmacies
Community Pharmacy Score Cards
Specialty Outpatient Clinics (not involved in management of complex hypertension)
Specialty Outpatient Clinics Score Card
Health Plans
Health Plan Score Card
Washington State Agencies and Local Health Jurisdictions
Washington State Health Care Authority Score Card
Washington State DOH and Local Health Jurisdictions Score Card
Employers and Health Care Purchasers
Employers and health care purchaser Score Card
Metrics
| Name | Title | Organization |
| Foundation for Health Care Quality | ||
| Virginia Mason Medical Center | ||
| Kaiser Permanente | ||
| Washington Department of Health | ||
| Community Health Plan of Washington | ||
| Virginia Mason Franciscan Health | ||
| Equity and Health Assessment Manager | Washington Department of Health |
Diabetes Care
Guideline title: Diabetes Care Report and Guidelines
Publication Status: Active
Date of publication: January 2024
Date of last evidence search: 2023
Scope: Team-based care and empanelment (ambulatory care, inpatient care, dental, health plans), population health, and minimizing financial burden and standardizing coverage.
Methods: Current guidelines and literature review and expert consensus
Description: Diabetes was selected by Bree Collaborative members in September 2022 and a workgroup of clinical and community experts met from January 2023 to January 2024. Key priorities to improve population health and equity are: Increase performance on NCQA measures for people who have been diagnosed with diabetes; Identify individuals with pre-diabetes or diabetes who are unaware of their status and engage them in treatment and prevention; Uniformly use team-based care to support individuals with diabetes or at risk for diabetes; Promote connection to community resources, address social needs, access to prevention and health promotion activities; Support patients’ medication and supplies use by removing payment barrier.
The checklist tool translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.
To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)
To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.
Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.
Ambulatory Care
Ambulatory Care Evaluation Score Card Ambulatory Care_Score Card_Final
Note: Metric 1-3 are not endorsed and should be tested prior to implementation.
Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.
Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.
Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period.
Metric 4 – Eye Exam for Patients with Diabetes (EED) (HEDIS) NQF# 0055, by race, ethnicity/language, insurance status
Metric 5 – Kidney Health Evaluation for Patients with Diabetes (KED) (HEDIS), by race, ethnicity/language, insurance status
Metric 6 – Blood Pressure Control for Patients With Diabetes (BPD) (HEDIS) NQF# 0061, by race, ethnicity/language, insurance status
Metric 7 – Hemoglobin A1c Control for Patients with Diabetes (HBD) (HEDIS) NQF# 0059, by race, ethnicity/language, select comorbities, insurance status
Metric 8 – Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) (Uses Electronic Data System (ECDS) reporting)
Hospitals
Hospital Evaluation Score Card Hospitals_Score Card_Final
Dentists
Dentist Evaluation Score Card Dentists_Score Card_Final
Metric 1 – Percent of patients who have been screened for a primary car provider visit in the last 6 months
Dental Plans
Dental Plan Evaluation Score Card Dental plans_Score Cards_Final
Metric 1: Percent of members who have been screened for a primary care provider visit in the last six months
Schools
School Evaluation Score Card School_ Score Card _Final
Health Plans
Health Plan Evaluation Score Card Health-Plan_Score-Card_Final
Recommended metrics for all patients and for inclusion into contracts:
- Social Needs Screening and Intervention (SNS-E)
- Adult Immunization Status (AIS)
Recommended metrics for prediabetes patients:
- Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.
- Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.
- Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period.
Recommended metrics for patients with diabetes and for inclusion into contracts:
- Hemoglobin A1c Control for Patients with Diabetes (HBD)
- Blood Pressure Control for Patients with Diabetes (BPD)
- Eye exam for patients with diabetes (EED)
- Kidney Health Exam for Patients with Diabetes (KED)
- Statin Therapy for Patients with Diabetes (SPD)
Washington State Health Care Authority
Washington State Health Care Authority Evaluation Score Card Health Care Authority_Score Card_Final
Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.
Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.
Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period
Metric 4 – Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) (Uses Electronic Data System (ECDS) reporting)
Metric 5 – Adult Immunization Status (AIS-E)
Metric 6 – Kidney Health Evaluation for Patients With Diabetes (KED)
Metric 7 – Eye Exam for Patients with Diabetes (EED) (HEDIS) NQF# 0055, by race, ethnicity/language, insurance status
Metric 8 – Blood Pressure Control for Patients With Diabetes (BPD) (HEDIS) NQF# 0061, by race, ethnicity/language, insurance status
Employers and Health Care Purchasers
Employers and Health Care Purchasers Evaluation Score Card Plans_Purchasers_Score Card_Final
Health care purchasers should consider including or requiring tracking of all recommended metrics on the Washington State Health Care Authority tab in this section.
Employers should consider developing measures for and tracking the following:
- Days of work missed due to complications from Diabetes
- Number of employees receiving evidence-based care for diabetes
- Number of employees with diabetes who have same day access to care
- Rapid return to function after diabetes complications
- Patient experiences with diabetes care
- Total cost of care for patients with diabetes
Confluence Health
In 2024 Confluence Health began a project to reduce disparities in Diabetes control between Hispanic, African American, and Native American Individuals compared to white/non-Hispanic individuals.
A summary of how they developed and implemented their project and their use of the Bree Guidelines can be found HERE.
Their report out for the final results of their project can be found HERE.
Community Health Plan of Washington
In 2025 Community Health Plan of Washington (CHPW) was awarded the Foundation for Health Care Quality’s Mountain Climber Award for the program in Diabetes Care. CHPW had previously won a Trailblazer award for concordance of care with Bree Collaborative guidelines. As part of their Mountain Climber award CHPW submitted a narrative summary and examples of their work.
- Mountain Climber Awards Summary
- Diabetes A1c Fishbone Diagram
- At Home A1c Workflow
- A1c Pilot Program FAQs
- North Central RTC Diabetes Project Poster
| Name | Title | Organization |
| Norris Kamo, MD, MPP (chair) | Section Head, Adult Primary Care | Virginia Mason Franciscan Health |
| Susan Buell | Associate Director of Health Initiatives | YMCA of Pierce County |
| LuAnn Chen, MD, MHA | Medical Director | Community Health Plan of Washington |
| Sharon Eloranta, MD | Medical Director, Performance Measurement and Practice | Washington Health Alliance |
| Rick Hourigan, MD | Market Medical Executive | Cigna |
| Carissa Kemp, MPP | State Government Affairs and Advocacy Director | American Diabetes Association |
| Vickie Kolios, MSHSA, CHPQ | Program Director, Surgical and Spine COAP | Foundation for Health Care Quality |
| Robert Mecklenberg, MD | Medical Director (retired) | Virginia Mason Medical Center |
| Mamatha Palanati, MD | Family Medicine Physician | Kaiser Permanente |
| Khimberly Schoenacker, RND, CSP, CD | CYSHCN Program | Washington Department of Health |
| Cyndi Stilson, RN, BSN, CMM | Care Management Manager | Community Health Plan of Washington |
| Sally Sundar | Program Executive, Health Integration and Transformation | The Y of Greater Seattle |
| Nicole Treanor, MS, RD, CD, CDCES | Diabetes Care and Education Specialist (DCES) | Virginia Mason Franciscan Health |
| Sheryl Morelli, MD, MS | Chief Medical Officer | Seattle Children’s Care Network |
| Leah Wainman | Equity and Health Assessment Manager | Washington Department of Health |
Community Health Plan of Washington was awarded the Bree Collaborative Trailblazer Award for concordance with best practice guidelines in 2024 and the Foundation for Health Care Qualities Mountain Climber Award for embedding processes to reduce disparities among those with diabetes.
Pediatric Asthma
Guideline title: Pediatric Asthma Report and Guidelines
Publication Status: Active
Date of publication: January 2023
Date of last evidence search: 2022
Scope: Asthma management across settings (school, clinical, home, etc.), care coordination, exposure reduction, funding
Methods: Current guidelines and literature review and expert consensus
Description: Given the multidisciplinary nature of pediatric asthma control, this guideline focuses on strategies to align efforts across key stakeholders. Guidelines are meant to supplement existing treatment guidelines from the National Asthma Education and Prevention Program, best practices for community interventions from the CDC’s Community Preventative Services Task Force, and expectations for pediatric asthma care in schools from Washington State’s Asthma Management in Educational Settings guide. Additionally, this guideline builds off previous work to mitigate the effects of climate on asthma from the Asthma and Allergy Foundation of America and offers strategies for funding pediatric asthma interventions drawing from previous research on funding mechanisms from the Brookings Center for Health Policy.
The checklist tool translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.
Resources and Tools
Link to National Asthma Education and Prevention Program
Link to CDC’s Community Preventative Service Task Force-Asthma Control
Link to Washington State’s Asthma Management in Educational Settings Guide
Link to Asthma and Allergy Foundation of America
ASTHMA AND HEAT
Clinical Overview of Heat and Children and Teens with Asthma
To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)
To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.
Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.
Delivery Site and Health Systems
Health System Evaluation Score Card Health System Score Card _ Ped Asthma2
Home Services Evaluation Score Card Home services score card _ Ped Asthma
School Services Evaluation Score Card School services score card _ Ped Asthma – C
Health Care Professionals (in development)
Health Plans
Health Plan Evaluation Score Card Health Plan Score Card _ Pediatric asthma
Purchasers and Employers
Purchasers/Employers Evaluation Score Card Purchaser payer Score Card _ Ped Asthma
Schools
School Score cards School services score card _ Ped Asthma – C
Guideline Metrics
The Pediatric Asthma work group’s focus was on cross-sector alignment to reduce the burden of Asthma in Washington. The group did not identify specific measures, however some standard metrics may be relevant to this work or are include in VBP contracts or HCA certification standards.
- Asthma Medication Ratio (AMR)
- The percentage of members 5-64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
- Child and Adolescent Well-Care Visits (WCV)
- The percentage of members 3–21 years of age who had at least one comprehensive well- care visit with a PCP or an OB/GYN practitioner during the measurement year.
- Potentially Avoidable Use of the Emergency Room
- The percentage of total ER visits considered potentially avoidable based on an agreed- upon list of ICD codes. This is considered a conservative measure of potentially avoidable ER use.
Improving Asthma Care Plan Documentation in ESD 105 Schools in Washington State: A simple plan
In 2024, Educational Service District 105 worked with the Bree Collaborative to measure the outcomes and impact of an implementation project aimed at improving the identification of students with an Asthma diagnosis and increasing school nurse documentation of Asthma care plans. EDS 105’s implementation strategy was to use existing meetings and trainings to make school nurses more award of resources for asthma care plan documentation, including the Bree Guidelines.
A description of their work can be found HERE. Results for increases in care plan documentation will be available in Spring of 2026.
ED and Outpatient Visits for Kids with Asthma: Observations during wildfire smoke episode in September of 2025
In 2024 Confluence Health participated in the Bree Collaborative’s Health Equity Action Collaborative. The project that they developed to address health disparities among Hispanic children resulted in the adoption and implementation of the Bree guidelines on the Health Impacts of Extreme Heat and Wildfire Smoke and Pediatric Asthma. Initial data from this project showed reductions in overall ED visits for children with Asthma and reductions in disparities between Hispanic and non-Hispanic children during the September 2025 wildfire smoke event.
View the one-page summary of how they leveraged Bree Resources to support their project.
You can read their presentation to their quality improvement team HERE.
| Name | Title | Organization |
| Annie Hetzel, MSN, RN | School Health Services Consultant | Office of the Superintendent of Public Instruction |
| Brad Kramer, MPA | Asthma and Community Health Worker Program Manager | Public Health, Seattle & King County |
| Christopher Chen, MD | Associate Medical Director | Washington State Health Care Authority |
| David Ricker, MD | Pediatric Pulmonologist/Sleep Specialist | Mary Bridge Children’s |
| Doreen Kiss, MD | Physician | University of Washington |
| Edith Shreckengast, MS | Clinical Health Coach – Registered Dietitian | Community Health Plan of Washington |
| Julee Christianson | Directory, Health Schools Program | Office of the Superintendent of Public Instruction |
| Kate Hastings | Senior Policy Expert | Scientific Consulting Group |
| Brad Kramer, MPA | Asthma and Community Health Worker Program Manager | Public Health, Seattle & King County |
| Katie Paul, MD, MPH | Physician | Kaiser Permanente |
| LuAnn Chen, MD, MHA | Senior Medical Director | Community Health Plan of Washington |
| Mark LaShell, MD | Allergist-Immunologist | Kaiser Permanente |
| Michael Dudas, MD | Pediatrician | Virginia Mason Medical Center |
| Sheryl Morelli, MD, MS | Chief Medical Officer | Seattle Children’s Care Network |
| Vicki Kolios, MSHSA, CPHQ | Senior Program Director, Spine and Surgical COAP | Foundation for Health Care Quality |
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