Addressing health care disparities can help practices improve the health of patients in vulnerable at-risk populations. Learn how eight family medicine practices boosted hypertension control rates for diverse patients by more than 3 percentage points in just three months.

A targeted pilot

As part of the Million Hearts initiative, the Summit County Public Health department (SCPH) and several partners in Ohio launched a pilot project with several family medicine practices to help reduce hypertension rates among black men.

In Ohio, 38.5 percent of black patients have a diagnosis of hypertension, compared to 33.7 percent for white patients, according to the National Association of County and City Health Officials. Black men are also 49 percent more likely to die from stroke and 21 percent more likely to die from heart disease than white men.

As a result of concerted efforts to combat these outcomes, in just three months, the eight practices reporting data in the pilot project were able to increase their blood pressure control rates for their patients with hypertension from 69.7 percent to 73.4 percent. The practices also saw the percentage of patients who scheduled follow-up appointments for their blood pressure increase from 66.0 percent to 68.8 percent. What was the secret to their success?

Improving disparities and health outcomes

Kristi Kato, a community health supervisor at SCPH, recently shared key insights on the project at a showcase of the Commission to End Health Care Disparities. She said the participating physicians and care teams improved blood pressure control among some of Ohio’s most vulnerable patients by:

  • Effectively using health IT to enhance clinical quality measures. 
    Some of these improved clinical quality measures “included the development of hypertension registries pulled from the practices’ electronic health record (EHR) systems and clinical dashboards to closely monitor hypertension control rates within the practices,” Kato said. These measures allowed practices to better identify patients with hypertension, compile key data about their outcomes and create targeted measures to improve their blood pressure control rates. “Participating family practices identified close to 12,000 patients with uncontrolled hypertension, which they defined as having a diagnosis of hypertension and most recent blood pressure reading of />140/90 mmHg,” Kato said.
  • Participating in official training sessions to improve team-based care and protocols for treating diverse patients with hypertension.  During the project, physicians and care teams—including family physicians, nurses, medical assistants, pharmacists and social workers—explored new ways to identify and care for black patients with hypertension. Care teams participated in an official team training day to improve processes and protocols for treating patients with hypertension. The training covered “the latest Joint National Committee guidelines for hypertension treatment, culturally competent hypertension care and team process mapping for identifying and treating patients with hypertension,” Kato said.
  • Focusing on the social determinants of health. Physicians partnered with the SCPH care coordination units to “address nonmedical social needs that may be barriers to disease management” for patients with hypertension, Kato noted about the project. Care coordination staff helped address several community services for patients, such as transportation, housing, counseling, dental care, food assistance, utility assistance, and vision and hearing needs. Staff at the SCPH also developed a referral form for practice teams to use. These forms helped improve referrals for patients with hypertension to ensure they secured much-needed resources. “Physicians or their staff could fill out the patient’s information—including what social service needs may need to be addressed—then fax or email the completed form, with signed patient consent, to the SCPH care coordination unit,” Kato said.

Explore these additional resources to improve your practice’s hypertension management

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