Implementing Self-Monitoring Blood Pressure Programs Using Telehealth to Address Hypertension Among High-Risk Massachusetts Residents

Posted on June 21, 2024 by Leah Greene

This entry is part 5 of 7 in the series CVD Prevention 1

Self-monitoring blood pressure programs are an evidence-based hypertension management intervention, but its equitable access among populations disproportionately affected by cardiovascular disease is a concern. The Massachusetts Department of Public Health worked with five local federally qualified health centers to implement and enhance SMBP programs to provide quality hypertension care to these populations.

Read the Article in JPHMP

Cardiovascular disease (CVD) is the leading cause of death in the United States (US) with hypertension being a major contributor. The burden varies widely among populations due to inadequate access to hypertension care and prevention. Additionally, the world was plunged into a global pandemic in 2020 exacerbating the burden of hypertension and its inequities. A series of executive orders by Massachusetts (MA) that required social distancing, stay-at-home orders, and telehealth reimbursement controlled the spread of COVID-19 and increased the popularity of telehealth visits. The increasing burden of hypertension due to the COVID-19 pandemic coupled with the executive orders created a unique opportunity to expand on providing hypertension-related care remotely through self-monitoring blood pressure (SMBP) programs. SMBP programs are an evidence-based practice facilitated by telehealth, in which patients monitor their blood pressure using a home blood pressure monitoring device to diagnose or manage hypertension. While its effectiveness is well documented in the literature, there are several barriers to access for populations marginalized by poverty, racism, and adverse social determinants of health (SDoH).

We used a health equity approach for program design by partnering with five local federally qualified health centers (FQHCs) across the state to implement SMBP programs using telehealth. This work was supported by the Centers for Disease Control and Prevention (CDC) through the Innovative State and Local Public Health Strategies to Prevent and Manage Diabetes, Heart Disease, and Stroke. We deliberately partnered with FQHCs that serve populations experiencing significant inequities. The program design and implementation were pragmatic and flexible rather than a standardized protocol to ensure that health centers could best serve their patients. However, the FQHCs were expected to:

Use their electronic health record (EHR) or other health information technology (HIT) to identify patients who could benefit from SMBP.
Enroll patients from populations that experience multiple barriers to managing their blood pressure.
Screen patients for unmet social needs.
Provide blood pressure cuffs to patients.
Use non-physician team members, particularly community health workers (CHWs) for patient outreach and follow-up.
Engage with quality improvement vendors to enhance existing their EHRs and HIT.
Have their non-physician staff complete free blood pressure trainings offered by MDPH to effectively teach new participants how to use their blood pressure cuffs.

Each FQHC implemented suitable, patient-centered telehealth models in collaboration with the FQHC Telehealth Consortium. The SMBP programs aimed to achieve blood pressure control for patients who were at least 18 years of age with consistently elevated blood pressure (>140/90 mmHg). Given the pragmatic nature of the program, we required the health centers to report the initial and final blood pressure recording and demographic information of at least 50 SMBP program enrollees for evaluation. Our findings are captured in our new article in the July 2024 issue of the Journal of Public Health Management and Practice, “A Case Series Study Assessing and Equity-Focused Implementation of Self-Monitoring Blood Pressure Programs Using Telehealth.”

Our Findings

Participants were mostly Black/African American (61.8%), non-Hispanic (70.5%), female (51.5%), English-speaking (50.6%), 45 years or older (83.6%), and were enrolled in their SMBP program for less than 90 days (54.8%).
Approximately 53.5% of SMBP participants experienced a decrease in blood pressure.
The average blood pressure decreased from 146/87 mmHg to 136/81 mmHg (p<.001).
On average, blood pressure improved in all racial, ethnic, and language subgroups.
Participants enrolled for at least 90 days experienced the largest drop in blood pressure by 12.35/5.95 (p<.001).

Implications for Policy and Practice

The SMBP programs succeeded for several reasons. Using an explicit equity lens and framework ensured that the programs reached those most affected by the structural drivers of health. Additionally, integrating CHWs into team-based care enhanced our health equity approach due to their unique understanding and experience with underserved populations. Creating a standardized protocol and workflow for patient identification, enrollment, and follow-up also contributed to the success of the SMBP programs. External partnerships in the community ensured that participants who presented with social needs received the social services and support they needed through referrals. Healthcare organizations who wish to implement SMBP programs as well should consider these points.

Please read our article, “A Case Series Study Assessing and Equity-Focused Implementation of Self-Monitoring Blood Pressure Programs Using Telehealth” in the July 2024 issue of the Journal of Public Health Management and Practice to learn more.

Acknowledgments: I would like to thank and acknowledge my co-authors and colleagues at MDPH for their tireless efforts on this project and article: Glory Song, MPH; Ana V. Palma, MPH; Claire Santarelli, RD, LDN; Caroline Wetzel, MA; Janet Spillane, RN; Victoria M. Nielsen, MPH. I would also like to thank the staff at the FQHCs for their cooperation and engagement with our team to make the SMBP programs a success.

About the Author

Leah Greene: Leah Greene is an Epidemiologist at the Massachusetts Department of Public Health in Boston, MA. She focuses on evaluating programs that focus on equitable cardiovascular disease care in healthcare institutions across the state and the association between cardiovascular health, social determinants of health, and health-related social needs.