Case Study: Connecting with Patients through Blood Pressure

Exama-Molin: I’m a nurse practitioner who manages the remote program with two medical assistants who receive and check all blood pressure alerts on a daily basis. I set parameters so they know what to do based off the reading they see. For example, if a patient has a systolic BP of 160–170, they’re supposed to call the patient as soon as they receive that alert, have them re-check it, ask whether they took their medications, whether they are having symptoms of chest pain, headache, etc., and use that information to determine next steps such as referrals or medication adjustments.

Exama-Molin: Our internal remote patient monitoring program started around December of 2020. We identified those patients in our practice who were not meeting our blood pressure goals of systolic of 140 or less, or diastolic of 90 or less. Once identified, we started supplying them with blood pressure machines to check at home. My team began monitoring remotely and it took off very quickly. In March or April of 2021, Chevonne from the Temple Center for Population Health contacted Excel to discuss the Frazier Family Collation and the AHA Target:BP program. Because we already had a remote patient monitoring program implemented, we put our heads together. They set up everything on the back end and all the programs came together.

The AHA Target BP program requires monitoring of blood pressure from our end. They also provided us with patient resources—videos, pamphlets—in both Spanish and English. They taught patients how to take their blood pressure properly, types of foods to eat, what systolic and diastolic mean, signs and symptoms to watch out for. Target BP really amplified the resources available to help our patients manage their blood pressure. All of our patients showed great appreciation for it.

Exama-Molin: Initially, the patients were somewhat irritated. If they have not used the device, we’re calling them; if their blood pressure reading is past the parameter that we’ve set, they’ve receiving a call. Some of them might receive a call two or three times a day. But after you have the same medical assistant calling them for two or three months, some of them would open up. We had a patient who had multiple deaths in the family during the pandemic, and that was contributing to the stress of their blood pressure being uncontrolled. So now the medical assistant was not just saying, “Did you take your medication?” They’re saying, “How’s everything else around you going?” Patients see that you’re invested in them, so why wouldn’t I invest in myself? That’s how we really got them to be excited. The model of the program is what helps you to get those patients invested.

Burden: From the practitioner’s side we didn’t have to set up much because Vanessa monitored the patients for us. But keep in mind that blood pressure’s just one metric—these patients have got a lot going on. It seemed to me to be a little disjointed just taking blood pressure out of the day-to-day equation. We thought our providers should take a more active role in the process so they could do the clinical management. We thought, let’s get these patients plugged back in to the providers.

Exama-Molin: How we did that was, as the provider in charge of overseeing the patients within the blood pressure program, if I made any medication adjustments, or I reached out to a patient’s cardiologist, for example, I would then text, call, or internally message their provider, just to bring everything together.

The PCPs actually enjoy and appreciate it. They are aware if I’ve made a change or a recommendation, and it shows the patient that the practice as a whole is working together and is invested in their blood pressure.

DaSilvio-Nash: All seven Excel practices that were in the TCIN network at the start of covered year 2021 (an additional practice was added mid-year as the EXCEL Medical, LLC acquired an existing TCIN attributed practice) performed very well with controlling high blood pressure. The average performance for BP control among Health Partners Plan members across all networks was 48.05%; TCIN practices overall were at 52.31%. The three top-performing Excel practices performed at 89.19%,, 78.95%, and 77.4%. (the highest of all TCIN practices). All Excel practices performed over 50%, and 5% higher than the plan which is the metric for meeting HEDIS payment incentive requirements.

Exama-Molin: We’ve noticed that when the patients are coming to the office, they’re happier about their blood pressure. We’re still educating them, but not really harping on them, because they are doing better. Now we’re congratulating them.

I have also seen a lot of the patients that were very uncontrolled, they would go to the ER quite a lot, for a [systolic] blood pressure that’s 170 or 180 and it’s really that they were non-adherent. Now they’re not going to the ER so much, they’re coming to their regular visits with me and they’re thriving.

DaSilvio-Nash: Practice operations considerations are definitely important when planning to develop and implement a SMBP program in the practice. The practice infrastructure and available resources such as staffing, staff training, and budgeting, to name a few are things to consider when developing a successful SMBP program.

For example:

• Available staffing to support and manage the workflow of the SMBP program. There are several operational workflow components that need to be developed in order to successfully manage a SMBP program.
• Access to available US Validated blue tooth blood pressure cuff devices that are compatible and data integration.
• Accessibility of Data and I.T. Technology
  • Blue tooth enabled self-reporting ability
  • Electronic medical record integration with vendor neutral-smartphone app
  • Cellular Data Transmission Options

Funding for a SMBP program is also something to consider. Some of the TCIN practices have received grant funding via the HRSA Hypertension Initiative which provide funding to health centers to support those centers that could benefit from assistance to help their patients diagnosed with hypertension control and improve their blood pressure outcomes.

Other practices, such as EXCEL Medical have used their own funds to support a SMBP program in the practices Therefore, partnering with the American Heart Association (AHA) is a really good opportunity for the practices to have access to patient educational and support resources, best practice publications, loaner devices such as eligible Bluetooth blood pressure cuffs that are interchangeable through the practice EMR system, and downloadable tools to assist the practice with implementing a SMBP program and Target:BP

Burden: That’s extremely important from the practice standpoint, the logistics. Hospitals have the resources to be able to pay for those things; private practices don’t. So cost-efficiency needs to be factored in.

Burden: We had this process set up before our involvement with Frazier/AHA, but as we joined other relationships, we realized the potential was greater than what we were trying to do by ourselves. The blood pressure metric was giving us a bigger picture of what was happening to our patients—not only on their blood pressure but on everything else they were doing. Some of these patients got really excited about following their blood pressure and doing the kinds of things that they should be doing, and they would come in and tell us, “My blood pressure’s been good!” Or, “Dr. Burden, the problem is my blood pressure.” The big picture is to make sure that they are invested.

DaSilvio-Nash: The TCIN is committed to working as a team to improve care coordination and the delivery of effective patient-focused care. Educating our patients on disease management supports better patient engagement, encourages healthy lifestyle change, and reduces length of stay and readmission rates and cost. It’s important that we identify those uncontrolled diagnoses, like hypertension, that are driving increased hospital admissions and readmissions to improve the health outcomes for our patients.