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Chronic Disease Management

Blood Pressure Screening and Control

Guideline Information

Guideline title: Blood Pressure Screening and Control

Publication Status: Active

Date of publication: January 28th, 2026

Date of last evidence search: 2025

Scope: Blood pressure measurement and screening for hypertension, individualized blood pressure management and goals, integrated team-based care to support whole person health and reduce inequities, and quality improvement and data insights utilizing the HEDIS Controlling Blood Pressure (CBP) measure and other data sources

Methods: Current guidelines and literature review and expert consensus

Description: Hypertension impacts about half of American adults, while only around a quarter have their hypertension under control. Hypertension prevalence and control varies between subpopulations, and these inequities are rooted not only in contemporary social and economic barriers but also in a long history of systemic racism, structural discrimination, and inequitable access to conditions that promote health. Practices such as redlining (residential segregation by race), underinvestment in communities of color, and exclusion from economic and educational opportunities have shaped the environments in which people live, work, and age. This environment influences diet, physical activity, housing access and quality, exposure to environmental stressors, and access to health care—factors all closely linked to risk for chronic conditions like hypertension. In addition, chronic stress associated with discrimination has been linked to hypertension, through physiological and behavioral pathways, compounding the effects across generations. Eliminating these inequities in Washington state will take coordinated, multilevel strategies that span sectors outside of healthcare. This report and guidelines focuses on the healthcare ecosystem’s role in addressing hypertension screening, control, and equity. 

Blood Pressure Screening and Control Message Board

Implementation Checklists by Audience

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.

Primary Care Settings & Professionals

Level 1

Level 2

Level 3

Health Plan

Level 1

Level 2

Level 3

Metrics and Evaluation 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.)

Introduction to Evaluation Tools

The Bree has developed multiple tools specific to the Health Impacts of Extreme Heat and Wildfire Smoke report, to support the evaluation projects implemented based on our guidelines.

Evaluation Framework

The Evaluation Framework provides further guidance on how organizations can conduct and align their work with other audience actors (example: all health plans in Washington state) or other audience types (example: health plans and providers). It provides specific details for measurement, provides strong and soft recommendations for the types of evaluations each organization may consider conducting, expands on alignment with other initiatives in Washington State, and makes recommendations for ethical and equity considerations.

EVALUATION FRAMEWORK

Data Matrix

An example of how to fill out this form is available in Appendix B of the Evaluation Framework. The Data Matrix tool can be used in planning your data collection effort for your implementation and evaluation.

Data Matrix Template– fillable form

Theory of Change

The theory of change illustrates how the work group conceptualized changes that would occur throughout the health care ecosystem as a result of their recommendations. The subcommittee for this report has not yet developed a theory of change.

THEORY OF CHANGE

Score cards

To support health system improvement the Bree Collaborative has created evaluation score cards that are designed to help measure progress on the implementation of our guidelines.These measures 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 and download the excel 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 Collaborative’s self-report data collection efforts. Organizations are not required to report, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.

Completed score cards can be sent to knicholas@qualityhealth.org

Score cards can be found in the tabs below:

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

Workgroup Members

Name Title Organization
Norris Kamo, MD, MPP (chair) Section Head, Adult Primary Care Virginia Mason Franciscan Health
Jake Berman, MD (vice chair) Medical Director for Population Health UW Medicine, UWM Primary Care and Population Health
Mia Wise, MD Chief Medical Officer Kinwell Health
Albert Tsai, MD Vice President AHA Puget Sound
Nicholas P Koenig, MD Internal Medicine Kaiser Permanente
Elizabeth C Slye, RN Registered Nurse Kaiser Permanente
Kimberly Parrish Director, Clinical Excellence WSHA
Josephine Young, MD Medical Director, Commercial Markets Premera
Laura Hanson, PharmD Ambulatory Pharmacy Manager Virginia Mason Franciscan Health
Nicole Treanor, MS, RD, CDCES Diabetes Education Program Coordinator | Registered Dietician Virginia Mason Franciscan Health
Kristina Petsas, MD Market Chief Medical Officer, PNW, AK and HI UnitedHealthcare
Theresa Kreiser, MS Senior Improvement Advisor Comagine
Katrina Gangsaas Community Health Supervisor YMCA
Mary Beth McAteer, MLIS Librarian Virginia Mason
Molly Parker, MD, MPH Population Health Jefferson Healthcare
Jessica Beach, MPH, MPA Health Equity Director Molina Healthcare
Leo Morales, MD Assistant Dean for Healthcare Equity and Quality | Co-director Latino Center for Health UW School of Medicine | University of Washington
Chris Longnecker, MD Cardiologist University of Washington
Eugene Yang, MD Professor of Medicine, Division of Cardiology University of Washington
Janice Tufte Patient Advocate Hassanah Consulting
Tonja Nichols, MN, RN Section Manager, Clinical Nurse Specialist | Clinical Quality & Care Transformation (CQCT) Washington HCA
Asher Strauss, PsyD Director of Behavioral Health Kinwell
LuAnn Chen, MD Senior Medical Director Community Health Plan of Washington
Jonathan Liu, MD Principal, Health Strategy Amazon (Global Benefits)
Jason Tzau, PharmD Senior Manager, US Health Plans Amazon (Global Benefits)
Sara Warner, MPH, CHW Manager, Community Support Services Community Health Plan of Washington
Karla Cowan, MSN, RN Occupational Nurse Consultant Washington HCA

Diabetes Care

Guideline Information

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.

Implementation Checklists by Audience

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

Level 1

Level 2

Level 3

Health Care Professional Checklists

Level 1A (all patients and people with pre-diabetes)

Level 1B (people with diabetes)

Level 2

Note: No level 3 for this audience

Metrics and Evaluation 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.

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

Examples of Implementation

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.

Workgroup Members

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

Award Winners

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 Information

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.

Implementation Checklists by Audience

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.

Delivery Site and Health System Checklists

 Level 1

Level 2

Level 3

Health Care Professional Checklists

Level 1

Level 2

Level 3

Public Health Agency Checklists

Level 1

Level 2

Level 3

Organizations Working with Community Health Worker Checklists

Level 1

Level 2

Level 3

Metrics and Evaluation 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.

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.

Examples of Implementation - NEW!

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.

Workgroup Members

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

Award Winners

Award Winners for Best Practices in Pediatric Asthma:

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