Before the COVID-19 pandemic, Southwestern Health Resources (SWHR), in the Dallas-Fort Worth area, saw its blood pressure (BP) control rates reach as high as 85%. During the initial part of the pandemic, though, SWHR experienced a drop in that rate to about a high 60% control. The decrease in BP control was due in part to the shift to self-measured blood pressures, many of which were not captured in the EHR, as well as a delay in patients seeking medical care due to concerns over safety during that phase of the pandemic. But, after assessing the new climate, SWHR made important changes to get their BP-control rates back up to about 78%.

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With their BP control numbers continuing to climb towards pre-pandemic levels, SWHR—for the second year in a row—earned Gold Status recognition from Target: BP™, a national initiative co-led by the AMA and American Heart Association. Target: BP offers annual, recurring gold-level recognition for all participating sites that achieve hypertension control rates of 70% or higher among their adult patient population, and participation level recognition for those sites that prioritize improving BP control each year and submit data.

SWHR joined Target: BP “because we have a significant number of patients with cardiovascular disease, including hypertension, and managing those patients effectively to achieve optimal health outcomes is our commitment to our patients and community,” said Jason Fish, MD, chief medical officer and senior vice president of SWHR, which is the patient-centered, clinically integrated network of UT Southwestern Medical Center and Texas Health Resources providers, and more than 2,500 community physicians.

“We really appreciate the approach tof the Target: BP Recognition Program—it resonates with us because it is data-driven and that’s exactly the way we approach our care delivery,” said Dr. Fish. “We are very passionate about cardiovascular disease and diabetes prevention and management, and we use data to inform our initiatives to achieve our outcomes—an approach that resonates with our providers and leads to the empowerment of our patients.”

Here are ways SWHR has improved its blood pressure control rate.

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“We looked at how we were doing collectively as a network and we realized, particularly in hypertension, that we had a tremendous opportunity in terms of being able to get to the level that we wanted to be,” said Dr. Fish. “We were hovering in the high 60%, low 70%, at one point a few years ago for hypertension control. “And that rate served as a wakeup call  to review how we were both measuring blood pressures and effectively preventing the sequelae from poorly managed hypertension,” he added. “As we gained greater insight into our processes and our data, we found opportunities for improved clinical decision support to capitalize on trends in blood pressures at the point of care rather than single blood pressure measurements.”

“We also found that where blood pressures were taken mattered—specialist versus primary care offices—and we started zeroing in on those differences and what we needed to do to improve our measurements and ultimately control,” said Dr. Fish.

“Our approach has always been to facilitate effective processes for our providers and staff, but equally it has been about empowerment of patients,” said Dr. Fish. “When the pandemic began, we found we had to rely on patients taking their own blood pressures, and because of our empowerment work, our patients knew what that needed to do to partner from home with their providers.

“We also had empowered our staff so when they were talking to the patients over the phone, they would remind them on taking their blood pressures: bare arm, feet touching the floor, no talking, resting for two or three minutes,” he said. “These commitments and processes helped us through the pandemic when we really needed to rely on our patients and their home blood pressures.”

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“We are now expanding our efforts to using artificial intelligence to predict patients who—based on a whole host of parameters including social determinants of health neighborhood characteristics—potentially could have progression of their cardiovascular disease,” said Dr. Fish, adding that this means “prediabetes to type 2 diabetes, or hypertension to heart attacks, strokes or heart failure.”

“Using an artificial intelligence approach to identify those patients at risk allows us to enroll them in a multidisciplinary program that includes our care management team in partnership with the physicians,” he said. 

SWHR is now measuring the effectiveness of these efforts, assess in disease progressed or there were unnecessary acute hospitalizations or emergency department visits. Additionally, SWHR has now added kidney disease to its current focus on cardiovascular disease and diabetes.

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