Home Blood Pressure Monitoring to Improve Hypertension Management
Our clinical guidelines recommend a two-week follow-up for elevated ambulatory blood pressure (BP), but access barriers create care gaps. To address this, we launched a telephonic follow-up program where a health coach educates patients on hypertension management, home BP monitoring, and device ordering. Using a population health tool, the coach identifies patients, documents results, and coordinates care. A pilot showed 62% engagement, with 21% achieving in-range home BPs (<140/90), while others were reconnected to care. Now expanded to seven sites, we've developed a replication playbook. This session explores workflows, challenges, successes, and program data.
Problem: Clinical best practice recommends rechecking uncontrolled blood pressure (BP) for patients with a diagnosis of hypertension within two weeks, but access barriers often make this challenging. Without a structured follow-up intervention, elevated BP readings may lead to clinical inertia or misdiagnosis of white-coat hypertension, impacting effective management and patient outcomes.
Measurement: We used a driver diagram to map key drivers, define our aim, and identify interventions. Bar and pie charts were created to analyze BP trends, primary care physician (PCP) engagement, and medication possession ratios to help us determine our project goals and timeline.
Analysis: We analyzed our results by tracking successful outreaches, patient engagement, and BP cuff distribution. A run chart was used to monitor the percentage of outreached patients with in-range home BP readings, helping us identify trends, shifts, and patterns to assess intervention impact and refine our workflow for continuous improvement.
Implementation: We implemented a health coach led BP follow-up program, to engage and educate patients on hypertension management, and procure BP cuffs. We addressed lost to follow-up, and pharmacy challenges by refining outreach, scripts, workflows, and prioritizing mail delivery. Our process can be adapted very easily by other organizations.
Results/Discussion: We engaged 62% of patients, collected in-range BPs from 21%, and ensured follow-up for out-of-range patients. Health coach drove enrollment and primary care connections. To sustain and improve outcomes, we will refine workflows and prioritize mail delivery of BP cuffs to patients.
Speakers
Manager, Quality - Boston Medical Center
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Performance and Process Improvement
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Location Virtual
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Organizer NAHQ Next
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