Needs and Objectives:
Poorly-controlled hypertension is associated with increased risk of adverse cardiovascular outcomes and thus is an important healthcare quality metric for primary care practices. Yet achieving blood pressure goals among socially-complex, economically-disadvantaged patient populations can be challenging due to cost-related non-adherence, poor health literacy and other social determinant barriers. Indeed, by early 2019, only 59% of hypertensive patients at our inner-city community health clinic had a blood pressure less than 140/90. The goal of this resident-driven quality improvement (QI) project was to increase blood pressure control among our hypertensive patients to a network target of 75% over 6 months.
Setting and Participants:
Our project was implemented at the Ryan Adair Center, a Federally Qualified Health Center located in Central Harlem that serves as a primary care practice site for Internal Medicine residents. The patient population consists predominantly of Black and Latino patients, most of whom are on Medicaid and live well below the federal poverty line. Our target population was hypertensive patients.
Intervention:
We used the Plan-Do-Study-Act method to carry out our clinic-based project. PGY1’s at the site served as the QI project leaders with faculty oversight. Cycle 1 focused on nurse education regarding proper blood pressure measurement. Cycle 2 focused on home blood pressure monitoring including patient education on proper technique and the importance of maintaining a daily log. Cycle 3 focused on assessment of health literacy via a patient questionnaire. Cycle 4 focused on provider education by ensuring that our patients were prescribed an appropriate medication regimen based on ACC/AHA Guidelines. Cycle 5 focused on referring patients with continued poor control to community health coaches to identify barriers like nutrition, medication access, and health literacy.
Evaluation:
Using our clinic’s online hypertensive registry (DRVS), we tracked on a monthly basis the percentage of hypertensive patients who had controlled blood pressure (<140/90). Percent of patients at goal went from 59% in February 2019 to 73% in July 2019.
Discussion/lessons learned:
Through this project, we demonstrated a meaningful improvement in hypertensive control among an economically-disadvantaged, racially diverse urban patient population. Accurate nurse measurements, engagement of patients in self-management, and resident education on evidence-based medication standards have all contributed to this success. Future directions will explore the impact of community health coaches in hypertension control and use of standard questionnaire to assess health literacy.
Socio-demographic, Clinical Characteristics and Status of Hypertension Control among Rural Hypertensive Patients
