CP35 - Team-Based Home Blood Pressure Monitoring to Improve Hypertension Control Among Uninsured Patients

Poster Type: Innovation

Primary Funding Source: American Medical Association, American Health Association, West Side United, Centene Corporation, NACHC and CDC Million Hearts® Innovation Award

Category: Quality of Care and Quality Improvement

Issue or Challenge: Esperanza Health Centers is a FQHC that serves a primarily Latinx population on Chicago’s southwest side. In 2018, Esperanza achieved a hypertension control of 80%, and we were selected as one of the Million Hearts® Hypertension Control Champions in 2019. However, amidst the COVID-19 pandemic, our hypertension control dropped to 58% in 2020. With the shift to telemedicine, we found an increase in the number of visits with no documented BP measurement and discovered uninsured patients were less likely to own a blood pressure monitor compared to insured patients.

Description of Innovation: We distributed blood pressure devices to uninsured and under-insured patients with hypertension through phone outreach and at our COVID19 vaccination sites, provided home blood pressure monitoring education and support to patients over the phone, and ensured patients followed-up appointments with their primary care provider. Strong evidence shows that home blood pressure monitoring plus clinical support helps people with hypertension lower their blood pressure. Home blood pressure monitoring enables providers to better manage hypertension and helps patients take an active role in the process. Furthermore, home blood pressure monitoring enhances the telehealth experience for patients and care teams. We utilized data from our EHR to help identify patients eligible for BP cuffs and leveraged Esperanza’s existing team-based care model. At Esperanza, care teams consist of a provider, a medical assistant, and a care coordinator who work closely together during the visit and in-between visits to provide high-quality care for patients. Every care team member plays a role in improving hypertension control. We developed a workflow that aligns with the care coordinators’ existing role in providing education, connecting patients to internal and community resources, and providing population health outreach to address patient care gaps.

Impact or Result: As of 04/08/2021, we sent BP monitors to 471 uninsured and underinsured patients with hypertension. Prior to our program, 17% of uninsured patients with hypertension had a BP monitor order. Now, 28% of uninsured patients with hypertension have a BP monitor order, which is an 11% increase. Of the patients in our program, 56% have a BP reading entered into their chart during the program measurement period. Since the program is currently underway, patients without a BP reading this year will have additional calls with their care coordinators and the majority have upcoming appointments with their primary care providers. We will continue to monitor the number of BP monitors sent to patients, the percent of patients with a BP reading in their chart, and the hypertension control rate for those patients. Additionally, we will monitor the number of care coordinator calls and telemedicine appointments with a BP reading entered.

Replicating this Innovation: For community health centers interested in adopting this model, we recommend establishing partnerships with organizations with technical expertise (e.g., AMA, AHA) for SMBP training and support, forging relationships with existing community-based organizations and coalitions, and collaborating with different departments within your organization to review baseline data on hypertension patients, create a workflow that includes EHR documentation, incorporate current roles involved with hypertension improvement efforts, and identify measures to track progress of new processes.

Author(s):

Sonia Ayala, MA, LCSW, Manager of Health Equity, Esperanza Health Centers

Rachel Cheung, Practice Transformation Associate, Esperanza Health Centers

Andrew Van Wieren, MD, Medical Director, Esperanza Health Centers

Carrie Kindleberger, APN, FNP-BC, Family Medicine Lead Provider, Esperanza Health Centers

Ted Hufstader, MPH, Director of Quality and Practice Transformation, Esperanza Health Centers

Paola Seguil, MS, RD, LDN, Quality Manager, Esperanza Health Centers

Rachel Cheung

Practice Transformation Associate, Esperanza Health Centers

Appearances