In three and a half years, a federally qualified health center in Texas saw a 30 percent improvement in hypertension control—boosting it to nearly 77 percent. The health center also saw a 38 percent improvement in its rate of BP screening of every adult at every visit.

The health center—Lone Star Circle of Care, headquartered in Georgetown, Texas—submitted data to show that it achieved a BP-control rate of greater than 70 percent and earned gold status recognition from Target: BP™, a joint initiative between the AMA and American Heart Association (AHA).

In 2018, the AMA and AHA recognized nearly 800 organizations for their efforts focusing on blood pressure control within the populations they serve.

Of the 80,000 patients at Lone Star, half are adults, with more than 9,000 diagnosed with hypertension. These adult patients are a challenging demographic to care for because about half are uninsured.

Through a grant from the AHA, 750 self-measured blood pressure (SMBP) machines were purchased. The SMBP machines were distributed to a subset of the uncontrolled hypertension patients at the health center. At the time the patients were given the BP machines, only 25 percent had controlled blood pressure.

“As of their last blood pressure reading, 60 percent of them are controlled,” said Tracy Angelocci, MD, during a webinar co-led by the AMA and AHA.

“That is a population, of course, that we will want to continue to follow and do some more studies on,” said Dr. Angelocci, the chief medical information officer at Lone Star.

Here are the steps Lone Star took to help uninsured patients measure their blood pressure at home and improve hypertension control.

Distribute BP machines to patients. To receive the BP machines, patients’ hypertension needed to be uncontrolled. This did not mean that at the time that the patient received the cuff that they had to be out of control. Instead, they needed to show a “pattern over the last year as being out of control,” Dr. Angelocci said.

Have patients maintain a BP log and agree to a return visit. Once patients received their devices, they also needed to agree to maintain a blood pressure log. This included daily measurements until their return visit. To document their blood pressure readings, patients can download a SMBP reading log from Target: BP, which recommends measuring twice in the morning and twice in the evening. Thirty days after patients received their BP monitor, they returned to Lone Star for a nurse visit to review their readings.

Use the EHR to identify patients needing monitors. When handing out the BP monitors to patients with documented uncontrolled hypertension, physicians, medical assistants and nurses needed to move quickly. Lone Star professionals developed a daily analytics report in the EHR system that listed who was scheduled to come in that day and who was likely to be a candidate for a take-home monitor. A separate report allowed staff to review any missed opportunities for patients who could have gotten a monitor and who didn’t.

“We need to create a culture that demands attention on blood pressure at every encounter,” said Dr. Angelocci. “Don’t place the burden entirely on the providers. This really should be a care team approach with everybody having some sort of expectations with what their role is and measure what it is they do.”

An AMA membership means you’re motivating millions to control hypertension. When the nation’s health is on the line, you can count on the AMA to be part of the solution.

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