Family Health Centers implemented a culturally and linguistically tailored nonphysician led, self-monitoring blood pressure (SMBP) program between 2020 – 2023 to offer patients a cost-effective alternative for managing hypertension at home.

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Compared to adults living in urban areas in Washington state, more rural adults reported having coronary heart disease and experienced higher mortality rates due to cardiovascular disease (1). Self-Monitoring Blood Pressure (SMBP) programs offer a cost-effective alternative for measuring blood pressure at home. Studies have shown that it leads to less intensive drug treatment and improved hypertension control compared to office treatments, especially when paired with other health interventions (2). Our evaluation titled, “Evaluating the Effectiveness of a Patient-Centered, Nonphysician Led Self-Monitoring Blood Pressure Program in a Rural Federally Qualified Health Center” assesses the implementation of a blood pressure self-monitoring program adapted for adults living in rural areas in Washington State.

Resource availability, healthcare access, and environmental factors in rural areas are key disparities that play a role in increasing hypertension risk factors. In 2020, COVID-19 became an added barrier, reducing in-patient appointments, and making hypertension management more difficult for rural residents. In response, Family Health Centers, a health system with 6 medical clinics, 2 pharmacies, 4 dental clinics, and 2 mobile units serving Okanogan County populations, implemented a nonphysician led, SMBP program between 2020 and 2023. This program was adapted to suit the linguistic, cultural, and transportation needs of the community, aiming to improve cardiovascular health outcomes using population health strategies, care-team coordination, and self-monitoring practices. Nonphysician staff who spearheaded this program included community health workers (CHWs), medical assistants, nurses, and pharmacists.

The University of Washington Health Promotion Research Center (UW HPRC) evaluated Family Health Centers’ SMBP program using a mixed-methods approach. The quantitative analysis evaluated patients diagnosed with hypertension who enrolled in the program versus those who, comparing demographic characteristics, physical activity and blood pressure measurements. 205 total patients enrolled in the SMBP program and tended to be non-White and Spanish-speaking and had a history of diabetes when compared to non-participants. The results showed that being an active SMBP program patient was not statistically significantly associated with having controlled blood pressure after adjusting for the following covariates: age, language, sex, and history of hyperlipidemia, pre-diabetes, and diabetes (odds ratio = .73, p-value = .06). Though these results seemed to indicate the program lacked effectiveness, other studies have demonstrated success with similar programs (2,3,4). There were limitations with our extraction of individual-level data that may have minimized the program’s impact.

In addition, semi-structured interviews were conducted with clinic staff to identify the facilitators and barriers to implementing an SMBP program for a rural patient population. The qualitative analysis identified 5 key areas of facilitators and barriers to the implementation of the SMBP program: COVID-19 Pandemic [as] a Catalyst for Change; SMBP Program Adaptation for Rural and Spanish-Speaking Populations; Reimbursement Barriers to Sustainability; Electronic Health Record Data Utilization for Reimbursement and Population Health Management; and Inter-Organizational Collaboration.

The interviews highlighted the Family Health Centers’ commitment to the success of the program and its adaptation for the local population. Bilingual staff and CHWs assisted patients in overcoming barriers with at-home blood pressure machines. CHWs also maximized their efforts to recruit Spanish speakers by disseminating educational hypertension information at community events and local radio talks.

Recommendations: The qualitative and quantitative results provide a case study and insight into implementing an SMBP program in a rural health center. We propose the following recommendations to overcome obstacles and ensure that the program is a long-term solution for managing hypertension. First, we recommend policymakers expand the definition of billable and meaningful encounters to accommodate and encourage essential services provided by nonphysicians, specifically CHWs. Secondly, we recommend additional funding resources or reimbursement of BP machines and cuffs to ensure consistent access and reduce reliance on grants and external agency funding. The expansion of billable encounters and reimbursement of equipment would support the financial sustainability of SMBP programs. Finally, it is important to consider policy options that can lower EHR costs and improve reporting capabilities. This will allow for a more thorough evaluation of the impact of SMBP programs. In turn, this will help clinics better assess and manage the health of their patient population.

Concluding Thoughts: We encourage you to read our article, “Evaluating the Effectiveness of a Patient-Centered, Nonphysician Led Self-Monitoring Blood Pressure Program in a Rural Federally Qualified Health Center,” published in the July 2024 issue of the Journal of Public Health Management and Practice, for additional results and proposed improvements on SMBP programs. We hope readers learn from our analysis and expand their programs to improve the well-being of rural communities.

Acknowledgments: We would like to acknowledge our co-authors at the Health Promotion Research Center for their contributions to this work, article, and blog post: KeliAnne K. Hara-Hubbard, MPH; and Bárbara Baquero, PhD, MPH. We would also like to express our appreciation to the staff at Family Health Centers for their ongoing dedication and hard work in ensuring the success of the SMBP program.

Sources:

1. Washington State Health Assessment—Coronary Heart Disease and Hypertension. Accessed November 11, 2023. https://doh.wa.gov/sites/default/files/legacy/ Documents/1000/SHA-CoronaryHeartDiseaseandHypertension.pdf
2. Tucker KL, Sheppard JP, Stevens R, et al. Self-monitoring of blood pressure in hypertension: a systematic review and individual patient data meta-analysis. PLoS Med. 2017;14(9):e1002389. doi:10.1371/journal.pmed.1002389
3. Eck C, Biola H, Hayes T, et al. Efficacy of hypertension self-management classes among patients at a federally qualified health center. Prev Chronic Dis. 2021;18:E70. doi:10.5888/pcd18. 200628
4. Lowe Beasley K, Tucker-Brown A, Rein DB, et al. Effectiveness evaluation of a hypertension management program in a Federally Qualified Health Center (FQHC). Prev Med Rep. 2023;34:102271. doi:10.1016/j.pmedr.2023.102271

Magali Sanchez is a PhD student in Epidemiology at the University of Washington, researching equitable strategies for influenza vaccination programs, and is a Graduate Research Assistant evaluating chronic disease programs across Washington state. She holds a BA in Human Biology from Stanford University and an MPH in Epidemiology from UW.

Amy Hernandez is a Research Coordinator at the University of Washington Health Promotion Research Center (HPRC). She graduated from the University of Washington undergraduate Public Health-Global Health major and is passionate about developing and implementing effective communicative healthcare tools for underserved communities.