Take it away, doctor Leticia I think you're on mute. You may have to unmute yourself Can you hear me now? Yes, we can. You're perfect Okay. Great, great, great, great, great. So I am glad to have the opportunity to introduce you to some fantastic work that's been going on at the at some of the grantees that we have funded through the American College of Preventive Medicine. So I hope you all are having a great day, and happy to have each of you here with us this afternoon. So today, we're gonna have some presentations from the American College of Preventive Medicine recipients. The Division for Heart Disease and Stroke Prevention was fortunate enough to award these grant opportunities to these recipients, and they were charged with developing innovative grant models with within their clinical practices to address hypertension, and what we have in a very disparate population of African Americans. So these organizations have been working for a number of years. Here to begin the work in these demonstration projects in at least 5 different areas. So our speakers today are going to be from the University of Alabama Medical Center. From Henry Ford Health System, From Cook County Health System, from the Lincoln Community Health Center and the Association of Black Cardiologists, Emory University School of Medicine and Grady Health Systems. So we hope that you are excited about these presentations. I surely am. They've been engaging in work to really look at these populations and to help us to better understand what we need to do to treat those persons that have hypertension and what new models and innovative models Should we be deploying in our work to further advance the care of these particular persons, so again, I'm excited for the opportunity for you to hear this today, and I'm gonna now turn it over to Dr. Ayanna Buckner, who's one of our medical faculty on staff at the American College of Preventive Medicine to share with you of these projects today, Dr. Buckner? Yes, thank you. Hi, everyone. We are so excited to have you with us. First, I've got to just read a brief disclaimer, and disclosure. This presentation is supported by the American College of Preventive Medicine, through a cooperative agreement with the Centers for Disease Control and Prevention of the US. Department of Health and Human Services. The contents are solely the responsibility of the authors from which you'll hear, and they do not necessarily represent the official views of nor an endorsement by the CDC HHS or the US Government. There are no disclosures or conflicts of interest to report from our speakers Next slide, and a bit of housekeeping. This presentation is being recorded. The recording in the slides will be shared with attendees. Closed captioning is enabled for the meetings. If you need it, please click, show captions on your zoom panel. All participants are on mute. We encourage participants to introduce themselves through the chat for the first few minutes. To direct traffic, all questions should be sent to the Q & A. The chat will be disabled after the first few minutes, and questions will be answered towards the end of the Q & A session. A present, say, or the Q. A. Session next slide So a little bit about the project as you've already heard, the funding is from the Centers for Disease Control and prevention, specifically from the division, for heart disease and stroke prevention. These projects are of a multi-year initiative to support the implementation of innovative approaches to identify and address uncontrolled among Black men aged 35 through 64, and also women with hypertension disorders of pregnancy. Grantees have been selected through an Rfp process and provided ongoing technical assistance to implement changes in their local health care delivery systems to bolster the detection, prevention and control of hypertension while also reducing social and systemic barriers to receiving optimal care. The demonstration projects have 4 Goals. First, increased screening and testing of black males at high risk for hypertension. Second, to refer, enroll, and engage these men and to evidence-based self measured blood pressure programs with clinical support and other related evidence-based lifestyle change programs, and then to also address social determinants of health that are identified as a barrier to patient screening, care, management, enrollment, or retention in an evidence-based SMBP program with clinical support or evidence to base lifestyle change programs. And then, lastly, to collect and report data. Obviously, that's very important so we want data that Reflects, experiences of enrolled men and assesses the impact of SMBP- of the SMBP program and other interventions during the project timeline. Next slide. Now we will hear from the University of Alabama. I look forward to your to hearing your questions in the Q & A period. Enjoy. I don't hear. Dr. Friend. Dr. Friend, are you speaking 1 second. Let me go ahead and take care of that right away. Okay. Yeah. Yes, I was trying to unmute myself. Hello! Good afternoon. Okay, there we go. Great Thank you. Very happy to be here today that I first would just like to tell the participants on the call a little bit about who we are. We're an Academic Medical Center in Tuscaloosa, Alabama. We have 5 clinics, 48 family medicine residents, 32 primary caretrack medical students. These are third and fourth year medical students who have expressed an interest in doing primary care when they finish medical school. We serve over 45,000 patients, 24% have hypertension. Of these 46% are Black or African American. And our hypertension control rate in this population is less than 50% Next slide. Please. Thank you. This slide is a workflow, and I'm I'm gonna walk through it with you all. Key to our process is our population health software, which is a part of our electronic medical record. And I'll talk a little bit more about that. At the end of my presentation with this tool we can identify hypertension patients by provider, and we use this to help our family medicine residents identify African American males, 35 to 64 who would be eligible for our 3 month, self monitoring blood pressure program. We're also now in this year using the Pop Health software to capture social determinants of health with Z Codes and then to track them geospatially. So the Pop Health software is key to this project. This is a very learner driven project. The family medicine residents are charged with reviewing their patient panels, screening eligible patients and then referring them into the 3 month program that I mentioned. So the the core to this program is really 3 things our residents, our hypertension care coordinator/LPN, and then finally, those medical students that I mentioned with the first slide. So the hypertension care, Coordinator enrolls patients, we use qualtric surveys to do some intake information, get baseline blood pressures, and then, of course, we give them an electronic blood pressure cuff, a lifestyle education book, and our medical students are then assigned to each patient, and are asked to call these gentlemen bi-monthly, to collect their blood pressures, to ask if they have set any lifestyle goals to see if they have any questions about the management of their hypertension, and really just to do some educated coaching with the patients. Next slide, please. Thank you. So successes. I think one of the things that I'm very excited about now that I'm actively involved with is getting our Pop Health tool to overlay patient demographic data with social determinants of health. We are using the PRAPARE Assessment Tool, and then it's embedded in. Next Gen, which is our Electronic Health Record. Once that tool is completed, it automatically generates Z Codes Which are associated with social determinants of health, and then we can look at that in our Pop health tool we have a very high enrollment rate/ 98% of the gentlemen that are approached agree to participate in the program. Again, I'm very pleased that we have team based care and our hypertension care manager, of course, is central to that and kind of collaborates and make sure that the patients, medical students and residents all stay engaged with the patient's care we have successfully partnered with our Wellbama Program, which is a program here at the University of Alabama for faculty and staff, where we provide health screenings and health education. We also have a partnership with a 100 Black Men of West Alabama, and their role is to mentor members of their organization, and they do a lot of outreach and health education. And then maybe most importantly, the sustainability of this program. I'm proud of, because I feel like it's you know, we're always gonna have learners. And so by using the residents, medical students, and also some social work students in the program I believe we are creating a future generation of socially conscious public health providers and hypertension prevention leaders. Our third and fourth year medical students now currently receive academic credit for participating in this program when they're doing their block of community medicine and of course that is been a Carrot that helps me attract medical students. And medical residents also earn credit for their required QI projects that they have to do for maintenance of certification. Next slide, please. Challenges. Of course there are always challenges, and I think what I have learned the previous couple of years is that not capturing social determinants of health really limited our ability to address hypertension control in this population. So I'm very happy that we're now gonna be using the PREPARE tool what I've discovered and will show you on my data slides. There are significant social determinants of health that chose this population and if I've known that upfront I might have been able to do things differently, engaging staff to complete prepare. They're all very busy. They have 15 minute slots to see these patients. Getting them engaged to do the assessment is something that I continue to work on. But I'm very pleased because people are are, understand the value of it. Finally engagement, getting the men to consistently record blood pressures. Sometimes having difficulty contacting men by telephone, we initially developed an app that I was very proud of. But the funding for that ran out, and it's very, very expensive to maintain a mobile app. Next slide, please Key takeaways, finding creative ways to make contact with patients between clinic visits are going to be critical. Changing culture at a large academic institution has been a long process. It's still ongoing, but it's very rewarding, and I think will hopefully lead some lasting changes, and then social determinants of health. What I have discovered, as I'm sure many of you do. Everyone deeply cares about their patients, and they want to help them. But our current fragmented system makes it quite difficult. I think the next slide is gonna show you a little bit of data. You can see that we work, the medical students work very hard. 200 and out of 245 calls attempted only 84 calls for successful which is a 34% call completion rate. Now I'm happy to answer questions about why I think that is in the Q & A later. But it is time consuming, and I'm proud of the medical students for their, you know, they stick with it. Next slide, please. Number of blood pressures participant--per participant. Excuse me. We've mapped this out nicely, and what you will see is highly variable, which in my experience I have patients that will take their blood pressure as many many times a day, and then some that you know don't take it at all so the average blood pressure is per participant that we were able to obtain in the follow up phone calls was about 9.2. So again, a lot of work from maybe not as much yield as we would like. Next slide. Thank you. Number of blood pressures per month. This was interesting. Some months, you know, we were able to get 54 calls, some months, only one. An average of almost 12 blood pressures per month were obtained, and this is using anywhere from 4 to about 7 medical students that we're doing this work, in addition to the care manager who was also trying to complete those phone calls. Next slide, please. And then I think this is probably the most compelling slide that I have to share with you. One of the things the's included in the follow up phone calls is a question where we ask patients, what barriers are they facing? Is there anything else that we should know about while we're not able to get their blood pressures to help them? And I think you'll see 47% of the patients just didn't really perceive the importance of this. So I I suspected that, and I think that has a lot to do with engagement. 90% of our patients have access to a smartphone or computer. So I originally thought, maybe that was a barrier, and I was incorrect. Blood pressure recording is not available at the time of the call. 25% would answer the phone "yes, I'm taking my blood pressure". But they didn't have their blood pressure readily available. And then another, very compelling piece of information, 28% reported that they were either in the hospital, not doing well or taking care of others. Next slide, please. Dr. Friend, you have 1 minute to wrap up Thank you. I'm I'm I'm getting there, I promise. So the next steps really to leverage a social determinants of health with PREPARE and Next Gen. Use this demographic data to better address our patients' social needs. Continue our partnerships and external, how we can enhance understanding of the consequences of untreated blood pressure. In other words, how do we make our patients perceive the importance of this. Next slide. And this is just a view-- I've got this slide, and the next one that kind of shows you the population health tool that I mentioned, what we are gonna be able to do is select the social determinants of health by the patients. And then if you click on the next slide, please, Anita. You will see that we can overlay that with zip codes based on their social determinants of health, and I feel like this will be a very good start to getting a a accurate picture of what social determinants Of health our patients are experiencing in order to help us prepare to address those. And that's the end of my presentation. I believe. Thank you all very much for your attention. Miss Eis. I just wanna confirm you're unmuted Yeah. Can you hear me? Great Yes, perfectly alright, so you can go ahead and get started. Okay, thanks. And I again appreciate being here today. And I'm from the representing, I should say, the Henry Ford Health organization in Detroit, Michigan, which is a large academic medical center in Detroit and surrounding areas with a highly diverse population. Next slide, please. So the main component of our initiative is addressing the disparities in blood pressure control for younger African-American males via what we call the Express Blood Pressure program, and that leverages the skills and strengths of a multidisciplinary team of pharmacists nures, medical assistants and community health workers, amongst others, with the goal of improving blood pressure control in the relatively short timeframe of 8 weeks, while also offering patient scheduling flexibility, self management support and also addressing social determinants of health. Next slide, please. This is a very quick process map for the program, and I'm going to focus a little bit more later in the presentation on the referral and patient outreach-- that seems to be where most of our challenges are. But this just gives a kind of a quick and dirty overview of the program itself, from inclusion to scheduling a follow up. So, next slide. And this slide provides an overview of the multidisciplinary team and their respective roles. So as you can see we have pharmacists, nures, MA's, case managers, CHWs, and more recently, we're adding on a dietetic student, which I'll talk about a little bit more as we go in as well. So some of the activities are very specific to the expertise and experience of the various disciplines. So the pharmacist does most of the medication activities, such as introducing new medications as well as titraiting. Whereas the nurses also do some titration, but get more involved in education, lifestyle coaching, goal setting, things along that line. And then other members of the team also have maybe some activities that may transcend across the various roles, such as distributing the home blood pressure, monitor devices if patient doesn't have one, or conducting the food insecurity survey, if that's not done, is that is our focus for a social determinants of health. Next slide, please. And this represents a flow chart that we created back in January of 2019, when the Express Blood pressure program was first launched, and it indicates the roles of the and the flow of the various disciplines from the provider the embedded pharmacists the rns in the titration program, as well as case managers. And my purpose of showing this to you. I'm not going to go through it line by line, but it is a live document. It's something that we do look at periodically, we revise it, based on need, as processes might need to be changed or tweaked. So we have done that as recently as October of 2021. And now with the inclusion of the community health worker and the dietetic student, we're going to have to Update it a bit again. But it is a live document. So I just wanted to share that. And next slide, please. And then this is a menu of the activities that we've been working on over the last 4 years. With the areas that are bolded, thethings that we're really focusing on mostly in this last year of the grant. So the the Express BP Program, the expansion of the CHW role. Continuing with our SDOH assessments and other things as well. So it's been a busy 4 years. Next slide, please. So what have our successes been? Basically our control rate amongst our enrolled patients in the target population is 52, and those enrolled in express BP have had a better sustained blood pressure control and med adherence than patients not in the program. Our satisfaction rates have been very high. Provider surveys have offered some insights into the barriers for blood pressure control. We do have a very engaged team recently adding a dietitian, a student, and an MPH. And then over the last year, 2022 specifically. the CHW role has been developed to enhance outreach efforts, patient involvement in self-care, distributing pill boxes for patient for better med adherence and food insecurity assessments. We've also created a comprehensive and sustainable patient educational materials, implemented AOBP devices at all of our clinics for standardized a standardized approach and improved accuracy of blood pressure and something we're really proud of being a top finalist for the Bernard J Tyson National Award for the Pursuit of Health Care Equity, administered by the Joint Commission and Kaiser Permanente. Next slide. So with successes also come challenges. Covid, I think obviously hits everybody equally, and we that led to some operational changes in the need to reevaluate some of our initiatives, particularly anything that we were doing in person. So we had to kind of zig and zag and and come up with some alternatives. So 52% of our patients enrolled are in control, meaning 48% are not so that's a a large group of patients that we still need to try to reach. And that's goes into the next bullet point of optimal outreach strategies for enrolling and engaging or patients. So I'll talk a little bit more about something that we're doing on that score in a minute. Maintaining consistency of processes amongst the team. You've seen, you know, flow charts, and we we do develop flow charts and algorithms for various activities, to try to increase consistency. But sometimes people do go off script, so we want to try to maintain that consistency and standardization as much as possible. We did create a QR code satisfaction survey had no uptake for it. So apparently not much of an appetite for that amongst our patients. Staffing changes, people coming and going, so that created some disruptions to our progress. Our CHW, He just left in December. So we're looking to re-establish that role and and replace that role as well. Sustaining the blood pressure monitor distribution is difficult. They are costly, and we can't always rely on our patients to give us the data that we're looking for in terms of their home blood pressure. Readings, our visits were meant to be 15 min in the express program. However, we know that they generally have exceeded that. We need a patient advisor still, and our food insecurity survey results have been lower than expected. Next slide. The key takeaways is the patient outreach, continue and continued engagement does require various strategies. The personalized outreach by the community health worker has demonstrated improved engagement and I'll show you a little data on that as well. And our data analytics team is invaluable to looking at our ongoing process improvements where we've been and how we're doing. Flexibility is vital. Plans don't always work out. And team communication is, of course, vital as well. So we're all on the same page. Again, consistently high patient satisfaction feedback. So we did eliminate the surveys, and utilizing lean tools and methods for developing workflow algorithms and process documents really helps support standardization and consistency for reliability of the data. And the food insecurity survey process may not be capturing our data as accurately as we had hoped. Next slide. So this is a patient outreach and engagement slide. And this just basically shows the funnel effect of all those patients who are eligible, and how it kind of funnels down to enrolled, and then actually controlled. So a third of our patients, a third of our patient outreach attempts have actually resulted in enrollment. Next slide. And this is what we plan to do in terms of referral and patient outreach. Our current state is there in the orange where we do initial out outbound phone calls to patients utilizing list of eligible patients, whereas our next process that we're going to try is utilizing the Cipher Health tool for automated texting outreach to patients mostly those that are in a higher priority situation, needing the pharmacist and the nurse, and we're slated to start work rolling that out in a week or two. So hopefully, we get a higher level of patients that are engaging. Next slide. And this is just a flow chart for the CHW. process. Again, we're introducing a new person into the role. So want to have that process standardized as much as possible, and just looking at a little bit of the data from what Andre, our previous CHW. Was able to do was a 47% appointment rate for the patients he was able to contact. So we were pretty happy about that. Next slide. And this is just some sustained blood pressure control data. Basically, the fourth bullet point is 70% of the patients given a blood pressure cuff maintained control versus 57% of patients without a cuff. And next slide. So sorry, Miss Eis. I just wanna say you have 1 min to wrap up, that's all. Okay, thank you. And our adherence assessment. This was conducted by one of our pharmacy interns the baseline of 111 patients. We had an initial adherence rate of 48%. But when some of the measures were implemented, such as education simplifying the regimen, providing the pill boxes and po packs and things along that line, it, it went up to a I believe it's 68%. My, yeah, I'm sorry. 65. So next slide And patient feedback. Again I mentioned that it was very high all along the way. We actually stopped utilizing them. The QR code didn't quite work out so well, but overall our satisfaction with our program has been very high, and patients comments one included. I wish this program was in place 15 years ago. So that was pretty gratifying to see which we had. But we weren't. So, thanks to the ACPM and the CDC. Next slide. And as far as next steps, I mentioned, we need to identify and train a candidate to fulfill the community health worker role. We have the person I identified. Now, it's a matter of training. We want to spread to an additional site in the first quarter of this year we have that site identified so that should be happening in the next month or so. We want to integrate the dietetic student in clinic operations to see patients for the DASH diet education, and conduct, a lifestyle presentation for providers on approaches to improve patient lifestyle choices. Pilot that Cipher technology for outreach. Focus a little bit more On virtual visits for the RNs, as well as creating a universal database for all support team members and identifying a patient advisor which we still need to do, and finally conducting a GIS assessment for our patients, particularly in in regard to our SDOH assessments for food insecurity and improving that process as well, as we know we're probably on the low end of getting positive numbers. And I believe that's it. Hi! Everybody! Hi! This is Chantal Tinfang for Cook County Health. CNext slide, please Anita. Okay, so Cook County Health Reducing Hypertension Demonstration Project. CCH is, provide health care to the people of Cook County of Chicago and surrounding counties. We have 2 hospitals, Stroger Hospital and Provident Hospital. Next slide, please. So probably in hospital, is the first Black owned and operated a hospital in the United States. It was founded in 1891 by Dr. Daniel Hale Williams, an African American surgeon, who performed the first successful open heart surgery. Next slide, please. Okay. During the first, the past 3 years we were seeing African American men with uncontrolled hypertension. We were giving them a blood pressure monitor to use at home. We were teaching them how to use the monitors, and we were having a class for them every month, hypertension class. For this year we are expanding by including women who are a friend, partner or family member of the enrolled men. The monthly Hypertension class will be opened to all participant of the same-sex clinic. We're gonna continue to provide on-site counseling, if needed. We're gonna refer patient to for exercise and for substance use disorder treatment. Next slide, please. This is our workflow at Sengstacke Clinic. So those men that we are seeing in our project. They they have been referred by the primary care clinic. We have a family medicine clinic with residency and the internal medicine clinic that works side by side. So once they refer those men, we give them an appointment to come to the clinic. Usually the clinic will call them to remind them to come to the office. They usually call them a week before the appointment. 4 days before the appointment, and on the day at the of the appointment we call them again to make sure they are on their way to come to the clinic. We do this to track and improve our show rate. We are, we are in the process of getting a CHW. That's going to help us make contact with those patient even before they come to the clinic for the enrollment. When they get to the clinic they they clerk checks them in. The medical assistant performs ambulatory intake and checks the blood pressure. So what happens is that if the in initial systolic blood pressure is 140 or higher, or if the diastolic blood pressure is 90 or higher, we confirm the blood pressure, how do we confirm the blood pressure? What we do is that we give the patient 3 to 5 minutes to relax. We make sure the empty the bladder. We position them correctly, and we check the blood pressure 3 more times after 1 minute, and after that we average the 3 readings. And that's how we confirm the blood pressure. When the provider sees the patient he will-- When I see the patient or my colleague, said the patient We looked at the numbers at home if they already have the machine. Or we look at the number in the office, and what we do is that after the visit, the first visit they will get the Monitor from the CHW. During the first visit, what we do if we focus on medication, we've performed hypertension education, we assess patient adherence to treatment, and then we look at the medication and see if we intensify the treatment. What are we going to do this year? We're going to refer patient to remote, patient monitoring. After that the M. A. discharges the patient, and the patient usually leaves the clinic with an appointment for what they coming back to see us. Next slide, please. Okay, our challenges. Some participants, we noticed that they were really struggling to Master SMBP techniques, so they have to sometimes come back and see the nurse. During the care management visit, we really teach them how to use the machine. We have ordered over 100 cuffs. And every time we order those cuffs we see that it comes with just normal regular adults sized cuffs. And so our patient need extra large cuffs. Some participants that we were referring, they have social economic barriers. They cannot afford to come to the clinic to check their blood pressure every few weeks. And the other thing is that some of them they have difficulty adhereing to medical treatments. Next slide, please. Hmm! Our successes. So this in 2021, during our joint commission, we mentioned this project to the people who came because we were getting the acquisition for PCMH, for Patient Center Medical Home. And they were very happy to see that we were doing this with our patient. The other thing that really helped the project was having another physician champion walking on side, sync, patient. With that one, we're able to see more people and expand the project. The other thing that works well for us is that the HIS department at Cook County helped us by making improvements to the software that we use. So right now, the next that we're going to do remote, patient monitoring. We're gonna be able to upload the SMBP readings from home into EHR. We're able to insert and have attention action plan for the patient to use so that they know what to do if the blood pressure is high at home. Next slide, please. Okay, key takeaways. This demonstration project have strengthened the communication between patient and physician. We see that SMBP is a powerful tool for the patient because it helps them. You give them power, and they can see that what they do affect the blood pressure, and they can have a sit at the table to discuss the help as far as blood pressure is concerned, and the other thing that we do on at stack is that every third Friday when we have a staff meeting. We look at our progress how we're doing with blood pressure, and we try to take action so that we can improve the number of patient that we seeing and keep them a target. Next slide, please. This is a graph with the monthly, the with the number of African American men out. Came to the Sengstacke clinic with blood pressure over 140 over 90. We did those by months. And on this next slide we have them by year, and we can see that in 2020, of course, we're still doing mostly telehealth. We have only 11%, but between 2021 and 2022 there were more than 10% increase in the number of men that came to Sengstacke with uncontrolled blood pressure. Next slide, please. This is the feedback that our patient are giving us, and they they really appreciate the fact that we can give them access to come and check the blood pressure every few weeks until they get to target. And they ppreciate the education that we provide. Because one patient said that this project, teaching him that if he continue to smoke or eat certain food, his blood pressure goes up, and they want to really get the blood pressure at target to prevent heart attack and stroke. Next slide, please. Next step for CCH. We hope that having a community health worker on site and practicing RPM in a way that is kind of efficient and responsible, we think that it will support long-term economic growth that we stay with CCH even after the grant funds end. Next slide, please. Yeah, we would like to thank you, the ACPM team. Especially Miss Balan, Miss Gay and Dr. Buckner. The CDC staff. Dr. Presley-Cantrell, Miss Buckley, Miss Ahmed, Miss Briscoe. And I would like to extend my gratitude to to my team at CCH. Mr. Brown, Miss Enogwe, and Dr. Turner. Thank you. Hi, everyone if we could also unmute Megan Gaines. She's gonna help me present this. We are at Lincoln Community Health Center here in Durham North Carolina. We're an urban community health center. We do about 32,000, or about a 100,000 medical visits here for about 32,000 patients. Now 93% of our patients are from a historically marginalized population. The majority of our patients with hypertension identifies Black. Oh, I can't. Sorry. Next slide. I'm trying trying to advance. So our project was we were trying to improve the blood pressure control in our Black male population, increase the number of Black men self monitoring, and introduce some protocols to try to optimize primary care visits and improve selection and advancement of blood pressure medications. Next slide. Our flow went- basically, I would run reports from our Electronic Health Record, EPIC, to identify all of our patients with hypertension in the first 6 months of the year. I sorted by the hypertensions, systolic and diastolic, and chose a cut point that seemed feasible in terms of the number of individuals we could reach out to with the the person power that we had. So we ended up with the first year 265 black men, with a blood pressure systolic either 160 or higher or diastolic 100 or higher. I then cut that list up into the number of students that I had and assigned them to reach out to those patients. The goal was to in the first year get the patients to come to a blood pressure class. We did a series of classes, and the second year and the third year was to reach out telephonically to try to help connect patients with a blood pressure cuff and education about how to use it. As part of the script, they were in the in the first year. We separately did social- we call them social drivers of health, trying to say that these are not determinants these are just drivers. We did, we doubt we did outreach for the social drivers of health by itself. In the first year, and in the second 2 years we we did a question that turned into multiple other questions that I'll get to about social drivers in the third call of the series of calls. We would then have the students help leave the patients through making a health-related smart goal and try to get a blood pressure reading back when the patient, after they got a cuff, and then at the end of the call series they were to try to reconnect the patient to our community health centers resources. Including a zoom class that we started in the year two. Next slide. So this is one of our in person-a couple of our in-person classes. Anyone who attended 4 different classes was deemed a hypertension hero, and had a little celebratory moment where everybody got a certificate who had attended 4 classes and clap for them, and you know made a big big to do of it. This is a difficult slide for me because 5 of the people pictured here are no longer with us, due to hard attacks and strokes. We found that when we reached out to these younger men we had very low uptake, but coming in for classes only 17 of the men who were actually on our list came to the in-person class. However, 93 patients come from our clinic didn't come to the classes 9 probations with with hypertension. Most of those patients who had attended were bBlack, and the people who attended more than one in person, class reduced their blood pressure by significant amounts. Almost 20 points to systolic and almost 15 points diastolic. There's a little log there. A gentlemen was 210 over 115 at the beginning of our classes, and at the end of the month he was down to 110 over 66. Like what did you do? And he said I just did what you all said. I just ate like you said and did some walking. Next slide. In the second year we had to go go virtual. These students all signed up to do in-person classes with us, and had to do we- we had to come up with something different. So we came up with scripts for calls, and tried to duplicate the content telephonically. This gentleman here, Daniel Tounsel, used to be a lawyer, and is now an NP. At our clinic during the course of our of our SDOH screen he came up with the idea of specifically querying for health harming legal needs, and really he assisted a lot of patients to expunge their criminal records to reinstate their drivers licenses, things that I would have never thought of. We found that when we open into to ask patients what they needed to improve their health. They provided much more to us than just food. insecurity and housing insecurity. They were asking for things like, a cane to get to the bus stop. Just things we found that asking the social determinant, social driver question as an open-ended question was much more fruitful and a whole lot faster. Next slide So this is year 2 only just kind of showing how things went. This is the the total that we reached out to, how many we reached, how many enrolled, how many we lost to follow up. I'll get to them more on the next slide. But just to point out people who interacted and engaged with the students really improved almost a 24 point drop in systolic, an 8 point drop in diastolic after the the calls. Next slide And in year 3, this is when Lincoln started working with students at NCCU. Which is a local HBCU and they collaborated with their nursing school specifically. It was formatted the same as the virtual class for Duke students, but this time it was in person. And both NCCU and Duke students helped lead this project. What we found is that patients who engage with the student and received a call, we're more likely to return for a primary care visits after that. Next slide, please. Year 3 is also when the Tuesday night patient education classes began over zoom. Dr. Biola was often the main person giving information and advised on blood pressure for patients but there were a variety of other guest speakers in other areas as well that attended. The format of this class was similar in year one giving hypertension, education, and helping them set health related goals and things like that. Next slide. And currently in year 4 this is when NCCU, Duke, and Lincoln are all working together. The students continue telephone outreach with patients that met that minimum blood pressure. And in the fall, this is when I join alongside the Duke students, we call 345 Black male and female patients, and currently, in the spring NCCU nursing students are calling a 190 Black male and female patients for a total of 535 in this year which is the most we've done so far. Next slide. So, I was asked for a data overview and sorry. This is just tons of numbers, but just shows how many patients were enrolled each year prior to I didn't put your 4 on here because we're not done with our data. But if you can just go to the next slide this sort of makes it a little clearer. This is just a summary. So we identified over the first 3 years of the project 647 people. One person apparently wasn't Black changed that. One person had transitioned to be a woman during that year. So we ended up with 645 Black men that we did outreach to reached about 60% over the phone. 83% of the people reached said they were interested, but only 38% of the people reached actually did complete either one in person, class or 2 calls with a student. 87% of the people who participated in that in that way, One class or 2 calls, got a cuff. And of the people who got a blood pressure cuff, 73% of them gave a value to the student later. So of the people, who originally said they were interested. Only 16% were hypertension heroes, completing the series of classes and 24% of the total were lost to follow up during the 3 years we identified 198 social drivers of health. Again, this was an open ended. I can share more about that at another time, but the students, came up with this. The students realized that if they started just asking a barrage a questions, people just tune them out. Next slide So some of the challenges included pre engaging, just changing everything all around in the face of lockdown. We found in year one that you can't just call call someone and ask about social drivers of health, you need a little warm up. So the students had a lot more success after they had a little conversation about blood pressure with people to then go to that next. It is a high administrative burden to to train and work with this many students, but we were impressed with our ability to broaden our reach with that. It's also been a lot of paperwork on my side to get everyone HIPAA certified and okayed and sharing data and using the spoofing software to say they're calling from our clinic. Next slide I do want to say, though, one of the things that I am so excited about. Our entire clinic has improved over the course of this project. If you look at the beginning of the project, our overall blood pressure control weight rate was 59% in our Black patients. It was 56%. This last year, 64.7% and 62% in our patients who had identified as Black. Really proud of that. That is not just the the hundreds of people that were involved in this project. That's our entire baseline of people with hypertension. Next slide. We have some other successes as well. Overall improving the health for patients. Of course, as you can see in this picture to the right. This is it, this is showing someone's log at one of those in person year one classes. They started at 170s 160s. Towards the end, we're at 140s and 120s. We also found that, being able to format this in a class allows us to use students who are typically enthusiastic about outreach and we're able to do this for low financial investment. That also teaches motivational interviewing, patient education skills to students who often want to enter healthcare improves health behaviors of students for themselves as they have to learn how to They can teach patient about patients, about this, these healthy habits, and it improves the reputation of Lincoln and the local Black community Next slide. Finally for some takeaways, we found that patients only improve if they engage in their own health care, and that's really important for prevention, and we found that students are able to help patients engage. However, it is hard to manage all of the student effort. It takes both time and effort on our end. So for the next steps we want to be able to have both Duke and NCCU students working together in the same class simultaneously to make things move more smoothly. And also we want to work towards sustain funding for this project Thank you so much to all of you. Okay. Hi, everyone. My name is Maya Stagg, and I'm a project manager here at Emory University and Grady Memorial Hospital, and our project is focusing on the post-partum management and navigation support for women with hypertensive disorders during pregnancy at Grady Memorial Hospital. Next slide. So just a brief project overview hypertensive disorders with pregnancy are a leading cause of maternal morbidity and mortality nationally, occurring in 5 to 10% of all pregnancy. And these disorders often continue into the postpartum period and disproportionately affect Black and Hispanic women. So here at Grady Memorial Hospital, we serve as the major safety net hospital for Atlanta and the Metro Atlanta Community, and 38% of pregnancies here at Grady were complicated by hypertension Which is 2 to 4 times higher than the national average. So what are we doing to address these statistics? We're utilizing a multidisciplinary team based approach and patient centered care model. We have 2 dedicated community health workers can serve as what we're calling health coaches to guide participants. through self measured blood pressure protocols, connect participants to community resources that address social determinants of health, and coordinate and monitor the scheduling and attendance of clinical appointments. And our targeted population are women with hypertension disorders with pregnancy at Grady, who have recently given birth and are on high blood pressure medication. Next slide, please. So here's a very condensed project workflow. We separated it into 4 different phases. Exc-excuse me. With the first day being 0, the pre-intention phase. And what we're really focusing on in this phase is identifying and screening potential participants. So we're doing this through registry referrals and review of various clinics schedules. So once we've identified the patient we moved into phase one. Within 3 to 7 days postpartum they'll have a home visit with MIH. MIH stands for Mobile Integrated Health. It's a program here at Grady that provides care at the patient's home. The community health workers will also attend this visit to deliver blood pressure monitor, a pillbox, as well as an educational booklet. And they focus on education, training and setting goals at this particular visit. Contact points in the first days are quite frequent with weekly telephone calls and or home visit with the community health workers. And then a key milestone in this days is attendance of the 6 week postpartum follow up, visit with their OB/GYN. So moving to phase 2, we go into bi-weekly contact points with the community health workers, and then we're really focusing on bringing the patients in to see a primary care provider at 3 months postpartum and a cardiologist for the cardiovascular risk assessment at 6 months postpartum. And then finally in phase 3, we have monthly cell phone calls, maybe health workers as well as our final profits, evaluation, data collection and data analysis. And it's important to note that throughout each phase, we're continuously collecting data, especially self-reported blood pressure measurements as well evaluating our processes so that we can enhance our program as we move through each stage. Next slide, please. So one thing I want to note, we just began enrollment in September 2022. So these are the successes, challenges, and key takeaways that we've observed so far. So I want to start with our successes. Participation in our program has resulted in an increased attendance at the 6 week postpartum visit. And I'll go into further detail about this particular success in the next slide. We've also implemented daily text reminders that resulted in an increase of self reported blood pressure measurements. And this text message is just as simple as "Hi. Good morning. I hope you have a great day. I just wanted to remind you to measure your blood pressure today." And it's proven effective so far. We've also been able to connect several of our participants to community resources such as Grady's Food is Medicine program, which is a food based prescription program. As well as provide a MARTA card to all that the participants in need of transportation. So our biggest challenge so far, has been SMBP at home. So, firstly, getting our mothers to sit down and measure their blood pressure. But also getting them to record it on either their logs that they that we provided them, or you know, in their phone app and then reporting it back to the community health workers. Which takes me to our key takeaways. It's been so important for us to meet our participants where they're at. Our population is mothers who have just given birth. So, developing this new habit, especially you know the habit of measuring your blood pressure daily. It can be overwhelming. And so acknowledging that and adjusting our plan to fit the needs has been effective. So, rather than asking for 2 daily measurements that we're aiming for, maybe at least one or 2 a week, and then progressing from there. We've also emphasized the importance of attending follow-up visits. You know it's a mom feels well, and the baby feels well, they tend to think that it's not, you know, it's not necessary to attend these follow up visits, especially the 6 week postpartum visit. So our community health workers have really focused on educating our participants on the importance of the visits. And then consistent communication from community health workers leads to small wins. Once we implemented the daily text reminders, especially for participants who weren't providing any measurements at all, we slowly but surely started to get an increase of self-reported measurement from these same participants. We also have regular, multidisciplinary team meetings to address challenges. And so we brainstorm on various ways that we can overcome these challenges. And then, lastly, we empower our community health workers. Our community health workers are the ones that are in the field, engaging with our participants. So it's extremely important to provide them with training and education to confidently take on this role of health coach. And so a few of the training that our community health workers have completed are the Healthy Heart Ambassador training, mental health first aid as well as internal training on motivational interviewing and nutritional and physical wellness. Mext slide, please So going back to the 6 week postpartum follow up visit. Historically the Grady OB/GYN clinic reports a 70 to 80% so show rate for attendance of this same visit. And if it's a standard of care, does it schedule from every mother who delivers here at Grady Memorial Hospital. And so out of the 32 patients that we've enrolled so far, 28 of them have reached this six week postpartum mark. And so out of these 28 patients, 32% were no shows. So this is a pretty significant difference from what the clinic observed on a larger scale. And this is mostly due to the multiple contact points with the participants between enrollment and postpartum visit. Once the community health workers enroll the participant, they're frequently reminding them of this visit, and it's checking the importance of it. Next slide, please. And so, what are our next steps? We hope to enroll the remaining 28 participants out of our goal of 60 participants. We also hope to implement physical wellness activities, as we have more participants moving into this phase 2, which is week 13, and through week 25. We feel comfortable implementing a physical activities into their daily routine. Whereas in the first days, you know, they're still in a vulnerable state, being freshly postpartum. And then, of course, we will continue scheduling these follow-up visit with the OB/GYN clinic as well as with their primary care provider and cardiologist and continue with our program evaluation and data collection and analysis. That is it. Thank you, everyone, for your time. Dr. Buckner I think I'm gonna have to unmute you. Just give me one more in place. Are you unmuted? I'm unmuted. Yeah, I'd I'd mute it myself. So thank you. I apologize for that. Those were some fantastic presentations, and I am sure that the attendees are as excited about them as I am. And to show us that please do continue to submit your questions, and in the meantime we will start working through the questions that we have received. So the first question is for the University of Alabama. Can you provide examples of what specific social determinants of health you capture? I think that, Kaha, if you can help me unmuteing Dr. Friend That would be appreciated. Thank you. Hi! Thank you for the question. So the PREPARE tool is validated. It is 17 questions, and it addresses homelessness, income, whether or not you feel threatened in the environment, so domestic violence, employment, level of education, and I think those are the ones that that we capture, and then they are automatically generated into z codes based on a score. Oh, and language- language spoken. so, I hope that answers your question, but it's P R A P A R E They have a great website. So please take a look at it. Thank you. Thank you so much for that Dr. Friend. The next question is for Cook County. Could you talk a little bit about what education is done during your visits, and how long your visits last? Thank you for the question. So at Sengstacke Health, what we do, the visit is scheduled for 20 min but sometime we go over the 20 min. We focus on education related to the, to understanding, hypertension. We have pre questionnaire and we have a post questionnare for the patient. And we also focus on teaching them how to read the food label and about exercise and smoking cessation. Thank you. Excellent, and so our next question will be for Henry Ford. Where can we find information- I'm sorry this question is from Wendy Bailey. Question is for Henry Ford. Where can we find information on the Express BP program? And can you talk more about the program? Yeah, sure, it's a program that we started back in 2019. And the idea was to use it at a couple of sites as a pilot program to engage both of our our embedded pharmacists, which we had at these 2 particular sites, with both sites having a high population of African American man with hypertension. So the idea was to have a place to go to identify these patients based on their age, their blood, most recent blood pressure readings, their medications. Those types of things and to reach out to them, to let them know that they were eligible for this specific program, where they could see a pharmacist or a nurse. So it really depended at least initially, our criteria was for patients that had more meds, more comorbidities would see the Pharmacist whereas those with lesser issues, maybe more. The the population of patients that were newer to being diagnosed with hypertension would see the nurse. All of them, of course, would have to see that be aligned with a primary care. Physician, but this was men as a so to the PCP. So that they didn't have to see these patients every other week and follow up with them as frequently, and allow the the physician to utilize their skills for you know more higher acuity patients. So the idea was to get them in, get them through the the program. Seeing the through the encounter to see the the pharmacist or the nurse in a relatively short amount of time, ideally 15 minutes. You get their blood pressure checked to get some basic education to tweak their medications if that was deemed as necessary, and then to schedule a follow up, as well as to administer a home blood pressure monitor for their use at home. And then, if they needed education on that, then we would involve the the medical assistants and actually teaching them how to use it, or if the Nurse or pharmacists had the time to do that, that they could do that as well. And now the community health worker is also involved in teaching patients on how to use the home monitor. So the idea was to sort of have a side route to having to go see the physician, to getting their blood pressure. Excellent. Thank you. This next question is for Lincoln, and it's from Anna Best Brown. I love this question. By the way, I want to hear more about your motto. "What's good for the heart" Yes, so that was from the urologists talk. It was the best attended talk of any of our nighttime zooms, it was that, but it was my favorite slide. What's good for the heart is good for the penis. Oh, the guys love that. Yeah, but it it really got everybody's attention. And that was a we actually that talk is up on our Youtube site. If you Google Youtube Lincoln Community Health Center and then go to these, I think it's there's a hypertension set of videos and one of them's like "Consequences of Hypertension" in his talk is there. It's like 20 min. It's good Thank you, Dr. Biola. This next question is, for Grady is the messaging and patient report of blood pressure via a mobile app used, or please describe how to duplicate those So the text messaging is straight from our community health workers. But we have provided options of already built apps that can remind patients to take their blood pressure, but also it has functions to remind them of their medications as well. But the daily text reminders that I mentioned in the slide are directly coming from the community health workers. Okay, thank you. This next question is for the University of Alabama. Can you talk about what type of social deterrent of health education is provided to the medical students who are involved with your work? Oh, that's a great question. Thank you. So they have several didactics on that while they're in their community medicine block. That's a a primary focus of that rotation. Thank you. Medical Center And they are required, while in that block, to complete a prepare assessment on on their patient, which I believe provides a very enlightening experience for them. I I hope this answers your question. Thank you. Thank you. And now let's see another question for the University of Alabama. And this question is from Michael Conyers. What are the typical times of day that the calls are made? That's a great question also. So it intake the the medical student. The nurse and the patient agree on the best times a day, best days of the week. So a lot of times it's after hours, even on weekends the the calls are made, in spite of having agreed upon those days and times. As you could see from my slide quite often patients are not a able to answer the phone, but it is something that's determined that intake. Thank you. So this is Anita Balan a host. If I may, I know Dr. Biola you had an interesting methodology with medical students, kind of keeping track of when the timing work, etc. Would you mind adding your thoughts to this question as well? Because I know that your medical students and your residents and nursing students also were having difficult time tracking when the best time would be to call the patients Yeah, they came up with this. So we basically in the the year, the the semester that we did the most calls, we put the entire list of 345 names up there and said, okay, guys, we don't want you all calling the same you know, people at the same time, and we, when we tried to give you just 10 each, like one of you, might end up with 10 patients, and one might end up with one person. So just to make sure you each get enough. What will do is we'll just say you sign up for shifts, you all know, when you're you know, they had a Google doc where they shared, and they knew that you know Megan was gonna do one to 2 on Tuesdays and somebody else is going to know 2 to 3 on Tuesday, and they would just start at the top and start calling, and they would note the date and time that they tried, and the next person who shift it was this is opening a shared spreadsheet and something called Box would know where to start. They know that Megan left off right here, and they would start there until until they had each accrued 10 patients or 12 patients, and then they would just keep that as their panel. But it came difficult, became difficult data. Wise to then slice that spreadsheet with 345 people up into pieces. And move it somewhere else for people to continue on so I haven't continued that, but I need to go back to it if we will if we're gonna do a high volume one again Back to you, Dr. Buckner. Thank you. Yes, so we've got 1 minute left. May I squeeze in one last question? Excellent. So this question is for Henry Ford, it's a question about the length of your visit, because it seems you include a lot of education and and intensive work with your own I'm sorry we asked that question already. Forgive me. Okay, one more question. And this question is also for the University of Alabama. Are you also recruiting nursing students as volunteers and potentially raising their social consciousness No, and the reason for that, Dr. Biola kind of referred to it. I believe, from the HIPAA implications, and the privacy and security things would prevent me from having those students reach out to our patients. Thank you. Thank you. Well, we are all out of time, but this is been a fantastic time together. This is a project that's very close to my heart. I can tell you that I've had a couple of family members hospitalized from complications of hypertension during the time that I've worked with this project, and I could not be more proud of the work that our grantees are doing. So on behalf of ACPM and our funders at CDC, we thank you so much for your time as well as our grantees on behalf of them. I thank you for joining us, and encourage you to stay tuned, because we will continue to share the great work. That our grantees are doing hopefully you'll join us at the Preventive Medicine Conference. You'll hear more from our grantees at that time. And also please stay tuned, because the recording will be shared with everyone who registered. So we wish you all the best. Have a happy Heart Month, and take care Thank you.

preventive medicine

hypertension management

underserved populations

self-monitoring blood pressure

lifestyle education

high-risk individuals

education

social determinants of health

postpartum management

patient-centered approach

health outcomes