All right, good afternoon, everyone, and welcome. This is a very special presentation about hypertension and health equity. My name is Dr. Stacey Schott. I'm an assistant professor of medicine at Johns Hopkins University School of Medicine and Cardiology, a preventive medicine physician, and the associate director for quality and safety in the Division of Cardiology. And I'm gonna help lead you through an exciting adventure where we moderate a great presentation about reducing hypertension in African-American men. So just to get started, we're gonna do a little housekeeping. And the wonderful presentations you will hear today, although supported by the CDC, don't necessarily represent official views of the CDC. And none of our speakers have any particular disclosures this afternoon. So what will our agenda be? So I'm gonna lead you through a little overview of this special grant program for reducing hypertension. I'm gonna talk to you about how the program was built, how we selected the grantees, the support that we provided to the grantees over several years, and then most importantly, we're gonna hear from the grantees themselves. So we'll hear from Cook County, Grady, Henry Ford, Lincoln, and University of Alabama. And after those presentations, you're gonna get the opportunity to ask questions about their work. So that'll be the last maybe 10 to 15 minutes. All right, and we hope through this session that you're gonna learn a couple things. We would like it if you would be able to identify at least two strategies to screen and refer patients into self-measured blood pressure programs. We hope you'll be able to describe at least two ways to provide optimal clinical support to engage patients in maintaining and controlling their blood pressure. And we hope you'll be able to describe at least two effective methods to screen and address social needs and barriers to effective hypertension management. So we all know this. The burden of hypertension is enormous. It's extremely prevalent, and in the U.S., perhaps almost 50% of adults are affected by hypertension. And of those, perhaps only a quarter are under good control. Hypertension is very costly. So in the U.S. alone, the annual expenditures reach nearly $200 billion, and it's a very disparate disease. So hypertension is much more common in non-Hispanic black adults than non-Hispanic white adults, and black men specifically have higher incidences of hypertension and hypertension-associated death compared with others, and challenges in following up with primary care and adhering to medical regimens that are provided. So knowing that this is such a burdensome, disparate disease and costly disease, the CDC has entered into a cooperative agreement with the ACPM for a five-year grant project. And here you'll see a list of some of the other cooperative agreements with the CDC. And today, we're focusing specifically on reducing hypertension among priority populations. So a little more about this special project. Again, as mentioned, funded by the CDC and the Division for Heart Disease and Stroke Prevention is about a five-year initiative to support innovative health system changes and approaches to identify and address uncontrolled hypertension among black men aged 35 to 64. And then I'll briefly tell you a little bit about how we selected each of these grantees, the process, and the technical assistance that we provided over the past several years so that they could complete their work. And the goals of this specific demonstration project were fourfold. We wanted to increase the screening and testing of black men at risk for hypertension. We wanted to refer, enroll, and engage these men into self-measured blood pressure monitoring programs. We encouraged grantees to address a social determinant of health that is identified as a barrier to their participation in such projects. And then we asked grantees to collect and report data about the experience of the enrolled men, the staff, assessing the impact of the SMBP program that they designed throughout their project timeline. So here's a little bit about the project timeline. The RFP was released in February of 2019. The grantees were selected in April of 2019. In May, they had an opportunity to do a startup project. And by July 2019, they officially launched their demonstration projects. And then, of course, we all know what happened in March of 2020. And you may hear about some of the challenges that came through the COVID pandemic in terms of how they implemented and carried out these programs. And then we anticipate that by July of this year, we'll complete the demonstration project period. And over the next year, we're gonna work to build sustainability of this important work and evaluate the program as a whole. So these are the sites that were chosen for this grant work. We're gonna hear from Cook County Health. And I wanna say thank you to all of the people listed here, Dr. Tinfang, Dr. Turner, Joy Anaguay, and all of the teams that work to Cook County Health. Grady, Dr. Linda Toomer, who you'll hear from today, and all of the supportive staff there that did this important work. The Henry Ford Health System in Detroit, Michigan, Dr. Denise White Perkins, Dr. Kalis, Dr. Octavia Solomon, who you'll hear from today. And Lincoln Community Health Center from Durham, North Carolina. Dr. Holly Biola is with us today. We thank her and her staff as well. And then finally, the University of Alabama at Tuscaloosa, Dr. Friend and Dr. Tamer El-Sayed. So a few more points before we hear from our grantees. Part of the support for this project, we provided assistance in the form of faculty mentorship and subject matter expertise. I served as one of those faculty mentors and along with Dr. Ayanna Buckner, who's the principal at Community Health Cooperative, and then Dr. Prentice Taylor, who is the vice president for medical affairs for Doctor on Demand Health Networks. And some of the work that we did with ACPM included the following. We had monthly calls with the project coaches and the ACPM staff. We reviewed monthly data, including qualitative data about the patient's experience and the staff experience. We reviewed quantitative data, including numbers of men screened, referred, and enrolled, how their blood pressure was managed over time. The grantees had the opportunity to speak with each other and share the challenges and successes on quarterly all grantee calls. We initially started with yearly in-person site visits with the grantees, and then that changed due to COVID, and now they are virtual. And we offered additional resources, including a shared network and partnership with other national initiatives, including Million Hearts and the National Hypertension Control Roundtable. The grantees also had the opportunity to take part in the lifestyle medicine core competencies curriculum. And then a really nice offshoot of this work has been the development of hypertension-related webinars that are hosted by the ACPM. And those occur maybe quarterly each year. So without further ado, I'd like to introduce our first speaker. So Cook County Health, Dr. Tin Fang is gonna speak. And she is board certified and family medicine physician and has been an attending physician with Cook County Health's ambulatory and community health network since 2009. She completed her residency with St. Mary and Elizabeth Medical Center Family Medicine Program and graduated from Heinrich University of Dusseldorf Medical School in Germany. Dr. Tin Fang, we thank you for your efforts and look forward to hearing about your project. Good afternoon, everyone. My name is Chantelle Tsing-Ting. I'm an attending physician at Senstack Health of Providence Hospital, Cook County. I am here today with Dr. Turner, who actually led this demonstration project. He's the interim chief health executive and medical director of Providence Hospital, Cook County. Overview of the health system. Cook County Health is the safety net health care provider for the 5.2 million residents of Chicago and suburban Cook County. Providence Hospital of Cook County is one of the two hospitals in the health system. Approximately 93% of people in the Bronxville neighborhood and on the south side of Chicago identify as African-American or black. This demonstration project takes place within the John Senstack Health Center, which is part of Cook County Health's ambulatory and community health network. Some historical context in cardiovascular health. Providence Hospital and training school was established in 1891 by Dr. Daniel Hale Williams, an African-American who was the first cardiologist to perform a successful open heart surgery. This is our workflow at the John Senstack Health Center. So those patients enrolled in the project refer to us by other provider at the clinic. So when they arrive to the clinic, they usually will check in with a clerk. And then our support staff will perform ambulatory intake, which includes general learning screening tools, social history, health risk screening, general health and medical history. We also do abuse and depression screening, social support and needs. And then the MA will use the seven simple tips to measure blood pressure and provide the machine to the patient that are first enrolled for the first time. Or for the patient that are returning for a follow-up visit, what they do, the RN need to upload the SMBP done at home into our system. And then the patient sees the provider. The provider reviews the reading at home and the reading in the office. Adherence is assessed and reinforced. Medication reconciliation is performed. We always use guideline-directed medical treatment. And after that, the nurse will perform discharge activities with the patient and hypertension education. The patient usually will leave the clinic with an appointment to come back. So if the blood pressure is not a target, the patient return to the clinic within two to four weeks. What Dr. Turner has done was to block slots on the provider that sees those patients so that they have access. So if they need to return, there's always an appointment available. During our project, we focus on social determinants of health. Clinician will order social worker referral for problems such as food insecurity. We have a food truck that comes to our health center. And we provide utility and rental assistance, care coordination service. For the patient with substance abuse, we refer them to the MAT clinic. And the one who needs screen positive for depression, counseling is provided on site before they leave the clinic. We also focus on health literacy specifically in relation to understanding hypertension. So we have a pre- and a post-assessment questionnaire that we use. This is our result from January 2020 to May 2022. So there were 13,733 clinical encounters for African-American male, age 35 to 64, were presented to the St. Stark Primary Care Clinic with a blood pressure of 140 over 90 or greater. The average blood pressure in that population was 164 over 100. As for May 31, we enrolled 100 participants. And the average blood pressure during clinic visit was 164 over 98. And the average blood pressure at home, the SMBP, was 152 over 93. During the project, participants often share information about challenges and accomplishments in their personal life that shed light on their level of engagement with the demonstration project. One participant who acted as a caregiver for his elderly mother and stepfather revealed the passing of his stepfather and how he wasn't thinking about his blood pressure then. Another participant felt surprised and proud that he was able to get his blood pressure to target after swapping a salty breakfast with fresh fruits and vegetable smoothie. And by him doing that, I was able to keep him on two medications instead of adding another medication. He was very happy with the change. And the challenges are lessons that we learned. Of course, COVID-19 pandemic was the first one. We have some staffing changes. We were dealing with staffing shortage, like everybody across the nation. And there was a closure of two of our health system outpatient community-based clinic. Those two clinics merged into Sendstack, so we had a bigger clinic. And then last year, we had a super staff strike. That went on for weeks. It was last year in June. It was very difficult for us to see patients without our medical assistant. And then we had another issue with the IT, with the Microlife BPA 2.0 software, which is the software that we use in the office to upload the SMBPs. But that issue was resolved. During the demonstration project, they were forthcoming about struggle with adherence. Like they were running out of medication, stretching medication. Ultimately, there were requests for refills or use of multiple pharmacies. And there was a knowledge deficit regarding how to go about getting refills. And we were able to provide teaching, because sometimes patients would think that they have to wait to see the provider to get the medication, when they can actually just call the pharmacy to get refills. There was a problem with the medical usage. So some of them, they were having challenge mastering the skill of SMBP. So it takes time to master that. And the only way is to meet the patient where they are, make them understand, and show them how to use the machine, like the correct positioning, the cuff placement. And once they master that skill, you could see how the BP would improve at home. And the other thing was that sometimes they wouldn't check the blood pressure. And there was a knowledge deficit regarding resetting the machine. There was a need for awareness about sodium restriction and transparency about struggle. So what we did, what we are doing right now, we're having a hypertension class with the pharmacist and the dietician. And the dietician usually will focus on teaching how to read food labels or give them option of healthy choices for breakfast or lunch. We are immensely grateful to the ACPM team, particularly Ms. Anita Balan, the director of the project, Ms. Taya Gay, and Dr. Berkner for her time and expertise. The CDC staff, particularly Dr. Presley Cantrell, Ms. Buckley, Ms. Ahmed, and Ms. Camaria Briscoe. And I'm immensely grateful to Dr. Turner, who is here today with me, for this opportunity and to Nurse Joy Egnugwe, who was seeing the patient at the beginning of the project. Thank you. Thank you. Great, thank you, Dr. Tinfang. I'd like to introduce our next speaker so this will be Grady Health System from Atlanta, Georgia, Dr. Linda Toomer. Dr. Toomer is the executive director of nursing for ambulatory care services at Grady Health System. In her role, she has divisional responsibility for nursing, clinical practice, and education in ambulatory primary care and specialty clinics and works closely with the provider and care teams. She is board certified in nursing leadership and ambulatory care. Dr. Toomer's span of influence includes 25 primary and specialty clinics, including seven neighborhood health centers, employee health and wellness services, and advice nurse programs, and two multi-service centers. In her work, she utilizes her longstanding leadership, quality improvement, project development, and grants management skills. Thank you for being here, Dr. Toomer, and we look forward to your presentation. Good afternoon. Thanks. I can get started on the remote. Okay. So, let me tell you about the Tougher Than Blood Pressure program, which is the name that we coined for our targeted hypertension program. I wanna share the project goals. We identified three primary care centers that we wanted to focus on. As you heard in the introduction, we actually have nine primary care sites and 21 specialty sites. So, the impact of our project was spread across all ambulatory clinics, specialty and primary care. We'll talk more about that as we move forward. We did wanna address a social determinant of health. We picked food insecurity. We planned to educate peer educators. We would train peer educators in SMBP, motivational interviewing, hypertension, and then they would train the trainer, so to say. They would come and support patients man-to-man and provide necessary education and training. We also worked very closely with our population health team to develop a hypertension resource bank, which could be incorporated in our EMR. And lastly, we built a database of African-American men seen in the ambulatory clinics who had a diagnosis of hypertension. And as we get toward the data piece, I will give you a little bit more details. Like everyone else, COVID hit and our project was semi-suspended during 2022. We couldn't get patients to come in. We had actually done this fabulous training for our peer educators. They themselves were patients. They struggled with depression, feelings of inadequacy, fear, anxiety, I don't know what's coming next. And so getting them to be a part of the program was a huge challenge. So we retooled ourselves and I'm gonna tell you how we did that. We didn't completely get rid of the peer educator program. We're phasing that back in now, but we had to revisit what we did. And here's what we did. We converted the peer education program to online, on demand and as available. And we made it available to our medical residents, our nursing residents, we widened the scope because you'll remember that even the academic programs were kind of on halt. Students weren't coming into the hospital. Grady's a huge teaching hospital. So they were suspended at home. So we started sharing this as a continuing education and getting ready for when we get back face to face. We used our hypertension database during this time to identify men who were at risk for being lost to follow up. We mobilized the clinical team at the three primary sites and we said, guess what? You are now going to be the outreach team for the target population. And we will then use our peer educators to support your work. We developed and implemented a nurse driven protocol for managing hypertensive patients. And when I say nurse driven, I don't mean LPN or RN, I mean the nursing team. So you will see how the care team, to be honest with you, MAs, LPNs, RNs, nutritionists, PharmDs, how the entire care team wrapped around the hypertensive patients. To address our nutrition focus, we screened all hypertensive patients, including the hypertensive men for food insecurity using a tool that we developed for our social determinants of health, food is medicine program. Now that tool was only two questions. What we found later on is that, see, I'm skipping a slide. What we found later on is that we identified low numbers with that tool, but there actually was a lot more food insecurity than we even knew. So, this is our workflow. The project team generated a list from our master database every month, at the first of every month, between the first and the 10th, and we sent the list to the three clinics. That list, before I leave that, was a 12 month look back. We're actually looking for men who were identified as hypertensive, but had less than two visits, because there's no way you can determine control if they don't have at least two visits. And that generated a huge list, I might add. Each month, that clinic-specific list of African American men potentially lost a follow-up was provided to the nurse supervisor, and they became the target for that month. The team made outreach phone calls to schedule the nurse visits, and the medical record was updated. Remember, these men had not been in for care, or they had been for care at a specialty clinic, because at that time, you didn't go. We weren't doing face-to-face. There were some areas that were doing virtual visits. We began to increase virtual visits in March of 2020. We started doing a whole lot of virtual visits. But for the most part, these men had not been in for care for a full 12 month look back. Some of them had changed their status. Some had relocated. Some weren't interested in having the conversation right now. Then, when they came in to the nurse visit, we did a baseline blood pressure. We did SDOH screening with a focus on the Food is Medicine program. We referred 100% of the men to the Food is Medicine program, because, I think I mentioned earlier, only 30% actually scored positive on that Food is Medicine two-question screening tool. So, we were starting the program. It was really new. We referred all of our men, and what ended up happening, we found out 80% of them were food insecure, because they weren't cooking for themselves. They weren't bringing lunch. They were eating on the job, whatever was convenient, and in addition to whatever was being done at home. We did training on use of the blood pressure cuff. We actually gave them digital blood pressure cuffs. We scheduled follow-up visits, and you'll see the nurse protocol in a second. That was an important part of the outreach, because we have an access issue. We only have so many providers, and this allowed us to reach far more of our target population, bring them in, begin the education, the training we needed, and that they needed based on their diagnosis, and then we were able to refer them appropriately based on an escalated protocol. Elevated blood pressures in the orange and red zone were escalated immediately, and we implemented a 24-hour blood pressure monitoring program for targeted patients. Okay, follow-up referrals were made for physicians, PharmDs, medical social workers, behavioral health, because remember, we may have screened them depressed, patient navigators to help close the loop there. We did nutrition classes as a part of the Food is Medicine program, and we gave them community resources. So I wanna quickly show you, we had some small numbers, but what it revealed was that we had a bigger problem than we thought. We only referred 272 programs at the time of this slide, 272 men across the three clinics for nurse visits. However, 40, 74, and 71 actually came in and had visits. Those are patients that wouldn't have had a visit before. Okay, now I'm gonna spend the last few minutes I have on this slide, because this is where we are now. This is part of a dashboard that we report every month to show hypertension control. So there are a couple of things on here I wanna share with you. In 2019, our hypertension control was 54%. In 2020, it was 45%, so there was a significant drop. In January of 2021, we had dropped a little bit more to 43%, and at the end of 2021, we were back up to 50% where we started 2022. And that's the number that we're working on now. So you can see some of the data here. You can see all of the primary care clinics. The green means that they met the target goal, and the target goal at this time is 50%. Just to show that red circled area, we have 71,000 hypertensive patients in those nine primary care clinics. 28% of them that we know of are our target male population. That's a little over 19,880, about that number. So we're talking significant, and when you see those small numbers, you're thinking, wow, but we made an impact, and we're continuing to make an impact. The take-homes, 29% of our African-American male target groups scored food insecure. 80% of them were after they talked to the nutritionist. 42% of our target group admitted to being depressed. Our peer counselors mirrored our population, which is why we're having to bring them back in. COVID negatively impacted. Of course, like everyone else, but the demonstration project provided tools and lessons learned that we were able to spread across the ambulatory primary care and specialty clinics. I cannot overemphasize the value of the care team. It takes a village. We had a huge food insecure problem. We're still working on that. Making those personal connections and outreach was the key to our success. Thank you Dr. Toomer and the Grady Health System for that important work. Next we'd like to hear from the Henry Ford Health System and I'd like to introduce Dr. Octavia Solomon. Dr. Solomon is a clinical pharmacy specialist and graduate of Howard University College of Pharmacy who practices in the family medicine and internal medicine clinics at Henry Ford Detroit Northwest Medical Center. Her pharmacy experience spans three distinct sectors including community pharmacy inpatient pharmacy and primary care clinics. In her current role she specializes in managing chronic disease including diabetes hypertension heart failure and ASCVD risk. She is passionate about addressing social determinants of health and improving medication adherence and access in minority communities. She has served as primary investigator and co-investigator on numerous quality improvement and research projects. Thank you Dr. Solomon we look forward to hearing from you. Good afternoon everyone. Today I will be sharing the work that we have been doing at Henry Ford Health System through the ACPM grant and the support of the CDC. I just want to highlight and share with you all a little bit about the Henry Ford Health System. It's a very large health system located in Detroit Michigan and we have more than 30 medical centers with more than 1,300 physicians located within the metro Detroit area. At the time of this grant implementation we had two programs within the health system that primarily focused on managing hypertension and those two programs were the RN blood pressure recheck programs and also the embedded clinical pharmacy programs. At the time of the grant we really took a look at what is our current state. How are we doing with controlling blood pressure across the health system and what you'll notice here is that our system wide quality goal is for us to have 80% of our patients achieve a blood pressure of less than 140 over 90. So you'll see the green line sets the standard for what our system goal is and then the orange line highlights where we were as a total population. So the entire health system how are we doing with managing blood pressure. Most of our we were at about a 76 to 78% goal for our total population. However for the blue line actually reflects our target population which is young African-American men and so our control rates for that specific group was somewhere between 64 to 66% which you'll see is significantly lower than our control rates for the entire population for the health system. So that really highlights the problem here with controlling blood pressure in young African-American males specifically at Henry Ford Health System. When we were awarded this grant we really took a step back in order to try and better understand our current state. What were we doing well what initiatives that we currently have in place how could we currently improve and so at that time we did some feedback surveys with our providers to understand what were some of their challenges and how they could you know and struggles with controlling blood pressure within their clinics. We also interviewed the top performing doctors within the health system to see what's been working well for them and then we took a look at the current workflows of the nursing and pharmacy programs to see how we could could improve them. For the remainder of this presentation I'll kind of focus on our big project which was the development of the express blood pressure program and the other highlighted components are really all a part of that. So we initiated a proactive engagement program where we reached out to patients to engage them into this particular service. We really wanted to make sure that we were reaching out to the patients versus just waiting for referrals from providers because we know that cannot somewhat be a bottleneck in terms of getting patients engaged. We provided patients with home blood pressure monitors. We wanted to offer them access to virtual visits. We engaged a community health worker and also provided patients with medication pillboxes and organizers. So to tell you guys a little bit more about our express blood pressure program I mentioned we had the nurse and pharmacy programs within the health system but we really wanted to take a closer look and leverage the strengths of each program to make sure that we were putting patients and matching them with the best service. Our goal was to get patients to go within eight weeks and to make sure that patients were placed in the service that aligned with their needs. So for the pharmacy programs we really focused on getting patients that had multiple chronic conditions who were on greater than two medications and who could really benefit from optimization of their medication based on their other chronic conditions. Our pharmacists typically make medication adjustments based on a collaborative practice agreement whereas the nursing visits are more focused on an algorithm based medication titration in which our nurses are very very good educators so they're able to take a lot of time to set lifestyle coaching provide education and set goals for the patient. And then lastly we wanted to make sure that we were increasing the flexibility of these visits so making sure that patients had access to more flexible hours quicker visits and even virtual appointments. We connected with our case managers within the clinic to make sure that we also were addressing and assessing their social determinants of health as well. This flow chart here kind of highlights the workflow workflow for the express blood pressure clinic. Our inclusion criteria for this clinic included African-American men within the ages of 35 to 64 who've been seen by their primary care doctors within the last six months. Patients could be engaged in the program either by a referral from the provider or by outreach again that proactive engagement of patients. The patients were then either scheduled with either the pharmacist or the nurse based on their specific needs and the goal was really for these visits to be quick visits for patients to be able to come in and out of the clinic without having to wait very long so that was very convenient for the patient. And so our goal was to have the appointment to last for about 15 minutes. We document the visit and the patient would be scheduled for follow up during that visit until they reach their target blood pressure. Here I've kind of summarized some of the things that we've collected and the outcomes that we've learned through this process over the last few years. Again this has been like a three year process so there's a lot to cover so I've really tried to highlight some of the key points here. In terms of patient engagement we've reached out or made more than 950 outreach attempts. More than 330 patients have been enrolled in the express blood pressure program and currently there's 178 patients that are at goal and have actually maintained their goal to date. We also have the home blood pressure monitoring program where patients are provided home blood pressure cuffs and we've provided cuffs to 165 patients. As a system we implemented food insecurity screening and this is for all patients not just for this project and in patients that receive that screen positive for food insecurity they were enrolled into something called Henry's Groceries where they receive shelf stable fresh and frozen foods in order to supplement one meal per day. And then lastly at each of the express blood pressure clinics we provided patient feedback surveys and what we learned through those surveys is that there was a strong likelihood for patients to recommend this program to their colleagues and family members. They felt like the visits were very efficient. They gained confidence in managing their blood pressure at home and they felt like the staff was very friendly and efficient. The one thing that's not listed here that I will highlight is that we also learned that our visits were taking a bit longer than we anticipated so we set the goal of 15 minutes but patients reported that their visits were you know 30 minutes. However we didn't end up changing our actual workflow because in spite of the visits being longer patients were still providing overwhelmingly positive feedback so we felt like it was still working. In terms of future directions and our kind of latest changes that we've made to the program we've engaged a community health worker to help us further facilitate this project and his primary role will be helping us engage patients that have been lost to follow-up. And also we know that one of the big gaps with the express blood pressure clinic is that we're targeting patients that have been seen by the provider within the last six months and we know that there are patients that perhaps haven't been seen for longer. So what he will do is engage those patients, get them scheduled with the provider and then follow them through to make sure that they're matched and linked with the appropriate program after that visit. He will also be helping us with completing the social determinants of health screening with each of these patients and collaborating with our community partners and then lastly we hope that he's able to even identify additional community partners or churches and things like that that we can collaborate or work with for our patients. We are also in the process of identifying a patient advocate so that we can hear more about the patient perspective when we're thinking about how we can modify our workflows and our community health worker will also be serving as a liaison for that person. I'm extremely happy about our community health worker that has joined our team. One of the things that we found very beneficial is that he's just able to really relate to patients. He's a young African-American male who has high blood pressure himself and so that connection I think will be pivotal in terms of forging our project forward over the course of the next couple years and moving forward. So in conclusion through our express blood pressure program we've been able to get 50% of the patients or more than 50% of the patients enrolled in the program to goal which doesn't sound like a lot but when you think of going from 100% uncontrolled to 50% controlled or more than 50% that's huge progress. But we do know that we still have a lot of patients that we're having trouble capturing and we want to make sure that we're able to bridge that gap for those patients that we aren't able to capture through the program. We also assessed the sustained results of the program and what we found is that when we compared patients that were seen in the express blood pressure clinics versus non-express blood pressure clinics we saw sustained blood pressure control in comparison to those non-express blood pressure clinics. So that's something we're really proud of. And then lastly I've already shared we've received overwhelmingly positive feedback and I'll kind of leave you with the point that I think really our biggest key to success and what we've learned through this process is that you really have to use the data and find ways to measure the programs that you're implementing. We can do a lot of great work but if we don't have feedback from the patients or methods of measuring our success to inform our decisions then we'll have a struggle kind of moving forward. And so with that we can transition to our next group and I hope to answer any questions you have towards the end. Thank you Dr. Solomon and Henry Ford Health System. Our next presenter will be Lincoln Community Health Center and we welcome Dr. Holly Biola. Dr. Biola is the Chief of Family Medicine at Lincoln Community Health Center, an urban federally qualified health center in Durham, North Carolina. She is boarded in family medicine, preventive medicine and geriatrics. She has worked her entire career in federally qualified health centers. She has a passion for highlighting root causes of health problems, largely social determinants of health. She strives to help describe mutable factors contributing to health disparities in hopes this will lead to improved health equity. She's quite accomplished in quality improvement work as well, consulting with North Carolina's Medicaid clinical policy and integrity units and serving quality improvement champion in two FQHC systems in North Carolina. Welcome Dr. Biola. Thank you. So I first just want to say a little bit about Lincoln. We were founded as the fourth black hospital in North Carolina, principally by the three black physicians there in the lower half and wealthy black businessman John Merrick. They convinced the Duke family, the top three folks on that little sheet, to help fund a black hospital in the black community. They had previously wanted to put a wing on the white hospital and they're like, you know, that's nowhere near where any of us live. So they were able to convince these men to do that. When Lincoln opened, it offered 24-7 inpatient and outpatient obstetrical and surgical services. It served from the get-go as a training institution for black physicians, nurses, various kinds of medical technicians, radiology technicians. And when the new county hospital was built and inpatient care was integrated, Lincoln was turned into an outpatient center in the early 70s, became a federally qualified health center. Right now we have 10 sites across Durham offering comprehensive primary care, integrated behavioral health. Most of our adults are uninsured. We live in a non-Medicaid expansion state. And 93% of the patients we serve self-identify as a racial or ethnic minority. When ACPM announced this grant in 2019, we were really excited to have the opportunity to focus on decreasing the disparity in blood pressure control between black men and the rest of our patients with hypertension. As an FQHC, we have federal reports that are built around certain chronic conditions and are able to just kind of at push of a button, starting about midway through the year, we're able to just download all the names of everybody with hypertension and look and see what their last blood pressure was. And while we would love to address all the 9,000 patients with hypertension at our clinic, we decided that with our staff, or lack thereof, we could manage to outreach to about the men who were 160 or more systolic or 100 or more diastolic, which was in year one, that was 265 men. And one of the minuses to being an FQHC is we don't have registries. So every December 31st, poof, all the people go away. And you have to wait until we accrue some data again for the year to start over. We had students call these men, the 265 men we identified, and briefly just let them know that blood pressures and the ranges they had at their most recent visit put them at increased risk of heart attack or stroke. The students then let them know that their care team at Lincoln was worried about them and really wanted them to come into this blood pressure class and get a free blood pressure cuff, learn how to use it. In order to get clinician buy-in and to best meet the needs of our community, we did want these classes to be open to all of our patients with hypertension, because when you start telling doctors that it's limited to certain ages and certain types of people, we just start tuning you out and say, well, I'm just never going to remember that at point of care. I don't even know who you want to talk to anymore. So it helped to just say, do they have high blood pressure? Send them downstairs. It's time for class. And we made overhead announcements with, I think we used David Bowie's Under Pressure to announce the class, but always lots of fun. One of our internists actually won a monetary award for her years of service. She was born at Lincoln Hospital, spent her whole career there, got this legacy award, and she gave the whole $10,000 to the Severe Outreach, Severe Hypertension Outreach Project so that we could offer cuffs to anyone who came to class, not just the black men. So that made it much easier for our clinicians to just go downstairs, it's time for class. We also were able to use the money she gave us for DASH-appropriate snacks, which the patients really appreciated. It's a lot easier to get people to buy Mrs. DASH once they've tried it and decided it's not terrible. So let's see. First-timers to class got their own blood pressure cuff, and we demonstrated how to use that. We demonstrated to them also how they could bring their own blood pressure down by doing a before and after, after a one-minute body scan meditation at the beginning of each class. Helped people sort of reset for class as well. We had four classes that we did on rotation, so the little didactic piece, the first one was about diet, the second was about exercise, third was about signs and symptoms of heart attack and stroke, and the third was an ask the expert session where we had a rotating set of folks that came in to help us, cardiologists, nephrologists, pharmacists, and a nutritionist. At every class we served one sliced raw fruit, one sliced vegetable, and some salt-free seasonings on low-salt crackers. We tried three types every class. This is an actual picture from my phone of the things that we let everybody choose. Okay, what are the three we're trying today? Everyone in the class, including the presenters, made a specific, measurable, achievable, relevant, time-bound, SMART goal for the week ahead, and repeat attendees were asked to tell us how they had done with last week's goal. I reviewed everyone's log and intervened when the numbers were really high. This gentleman, this log here, you can see he starts 160s, 170s over 110s, and ends the month at a much better place after I asked his doctor would they consider HCTZ for him as an addition. Here's another log that is very difficult to read, but he starts at 217 over 115. Asymptomatic, didn't have to send him anywhere. Ends the month at 110 over 66. Didn't faint or anything. I asked what he did, and he said, I just did what y'all talked about in class. I just walked and changed my diet. It actually works, people. Really exciting to know that, because you never get to see it in real life. From August 2019 to March 2020, we had 28 classes, and 93 different individuals came to those classes. We made it clear that while everyone was welcome, we were intentionally focusing our efforts on the health of black patients, and we talked openly about the disparities in morbidity and mortality with the students. And maybe due to this overt focus, the majority of people who were repeat attendees were black men. After attending four classes, people were recognized as a hypertension hero. We had a little celebration at the end of that class when we had anybody who was at their fourth. You can see the blood pressure drop for repeat attendees was almost 20 points systolic and almost 15 points diastolic. This slide is difficult for me, because for the people in this photo who are no longer with us, that is why we do this work. So COVID stopped our in-person classes cold. We regrouped our clinic. We were instrumental in testing and vaccinating our community. Dr. Granger, who was a nursing professor at Duke who helped me with staffing of our classes because they became quite the production with the serving of food and the experts that came and the videos and everybody getting taught how to use their cuff. It took a lot of people to make that happen in a fun way. So she and I agreed that we would have this class of health profession students that would help us with class in the following year. We had already signed them up. And then COVID hit, and we weren't allowed to have class anymore. So we had to not only figure out how to support and help our patients, but what to do with these students who had enrolled in a class with us. So these are our students. All in Zoom. We all learned. Remember when we didn't know how to Zoom? So together we tried to take the content from our four in-person classes that we had been teaching and develop them into four scripted calls that the students would use to telephonically outreach to the patient and help them self-monitor, help them get a cuff and self-monitor. This is what the students did in year two. So in the year two group, we had 258 men on it. Remember, poof, the 265 went away. Now we have 258 in mid-year of year two. So they were able to reach 137 of these men, which is about average for a reach-out to our patient population. 108 of those patients agreed to be called again for this group or for this telephonic support. 82 of them actually got a cuff during the year, which was incredible to me. They were ingenious, these students. They were meeting them in the parking lot of their complex or McDonald's or in front of the clinic. This all needed to be done outside. In some cases they mailed them. Our group leaders, we had four graduate students and the rest were undergrads, the group leaders had cars, so they sometimes would take their team on a little tour of the community and drop off blood pressure cuffs and actually meet the patient, which was fun. Of those, 43 men actually reported blood pressures from their cuffs. So of the 82 who got cuffs, only 59 picked up the call again for the next, oh, call. I better speed along here. One of the things we found in trying to do social determinants work was that you can just ask people what they need and they will tell you. You don't need to read them a laundry list of 30 things that they might possibly need. That was fantastic to learn, I think, for the patients as well, because they did not appreciate the long calls. What we asked was, while I'm calling you today about your blood pressure, we at Lincoln care about other things that affect your health, too, are there any resources that I can connect you with that might affect your health, and we gave a short list of options. One of our students had been a lawyer prior to going to nursing school and actually spent the summer delving into all of the social determinants needs that had been identified in the prior two years. He found that some of the needs were persistent in spite of us having given what we thought was the appropriate resource to the patient. Duh. These things do not go away. Food insecurity is a chronic condition, not just something you can fix with a SNAP benefit on one day. One of the things he found was some of these men had health-harming legal needs. They needed their record expunged. They needed their driver's license reinstated. They needed appeals for SNAP benefits, for disability, for Medicaid, so he was able to help us connect more people to a medical legal partnership through that referral. One thing I had not counted on was that the students themselves reported health benefits themselves after walking the walk, after doing all this preaching to the patients. One of the students was a black man with hypertension who started monitoring his blood pressure. One student lost 20 pounds, and I was like, oh my God, I hadn't even thought about the students, wow. We really need to get to this community of students, why don't we start a little younger? We're Preventive Med Docs, right? So we marched down the street to our local historically black university, North Carolina Central, and said, can we partner with you? Because the Duke students don't really need us that much. So they did great, but. So this year we've been working with North Carolina Central students using and tweaking as we go the scripts. This is why I love QI work, is you can tweak things and change things. And I'm really proud to say that the increased focus on cardiovascular health at our clinic has affected not just the patients that we've reached out to, but our whole clinic. So again, I mentioned we're much smaller than the other places. We've got 9,000 patients with hypertension. So when you see percentage point changes, that's a lot of people. We improved by two percentage points overall, and our black patients improved. Thank you, Dr. Viola and everyone at Lincoln Community Health Center. So our final presenter today will be the University of Alabama at Tuscaloosa, Dr. Luann Friend. And Dr. Friend is an Assistant Residency Director for Research and Quality Improvement and an Associate Professor in the Department of Community Medicine and Population Health at the University of Alabama Tuscaloosa. In these roles, she ensures that family medicine resident physician learners achieve their ACGME scholarship requirements. She also serves as the Interim Chief Nursing Officer for the College of Community Health Science. Dr. Friend has extensive critical care clinical nursing experience, in addition to expertise teaching at both the graduate and undergraduate levels. Her funded research targets the screening, diagnosis, and treatment of hypertension. And she's made a significant impact on incorporating SMBP and lifestyle management skills into both medical student and medical residency curriculum. Thank you, Dr. Friend. Thank you. Good afternoon, everyone. I'd just like to say how nice it is to see all my fellow grantees in person. This is the first time in three years. So goodbye, Zoom, I hope. I just wanted you to know that before we were fortunate enough to get this funding, hypertension was really a practice priority for me. We had embedded an electronic health record template. We had interprofessional lifestyle training. So to get this award was magic, because it was an opportunity to really target a very priority important population, as we've already discussed. And so it was very exciting and continues to be. And I've learned a lot. We have a lot of clinics. We're the largest primary provider in Western Alabama. We have over 70 providers. And what's important for, I think, you to take away from my presentation is that we have 48 family medicine residents. And we also have 32 to 34 per year medical students from what is now known as the University of Alabama or HERSINK School of Medicine, previously UAB. Very simple concept that we've developed. We feel like if you identify someone, we looked particularly for poorly controlled or newly diagnosed hypertension patients. Employ self-monitoring blood pressure, increase patient engagement, and hopefully reach blood pressure control. We focused on our resident clinics, because in a minute you'll figure out that this was primarily resident driven in year two. And around 1,482 African-American males between the ages of 35 to 64 were in those two clinics. So we had a nice target of people to screen and recruit. The first year, I was very fortunate to have an African-American LPN who was very energetic, very passionate about this program, worked part time with me. What we did is we had an interprofessional hypertension class that included nursing, medicine, pharmacy, social work, because this is a chronic disease. And we talked to them about managing chronic diseases. And also our nutritionist, who is key to any program. We provided patients with automatic blood pressure cuffs who agreed to participate after the class. And these patients were called by the LPN, Regina, once per week for lifestyle coaching. Like most of the grantees, we provided them with blood pressure cuffs. We had also developed a hard copy hypertension lifestyle book and instructions for how to download and use an app that we developed, written instructions on how to use the blood pressure cuff, logs to record readings, and a nice little tote bag to carry everything in. Before they left the class with the cuff, we taught them how to use the cuff, because that's one of the hardest things. This is a brand new skill. And so I just want to share that as something that's also essential to doing this kind of program. Initial blood pressures, you can see we were dealing with quite a range of hypertension in our initial diastolics. How many people? Talk about low numbers. I feel like the underachiever in the group. But we were focusing on a process and trying to identify what worked. So we had 11 males enrolled and complete. This was a 12-week program. It's interesting trying to determine how long your program should be, which is another question. You can see the demographic age there. Smoking status, about half and half. A lot of smokers in the South. Physical activity status. A lot of them were physically active, but also a lot of them worked for our grounds department at the University of Alabama. So they were quite active, I think, just by their employment. 10% reached goal, which I think is huge, considering we had such high blood pressures. And most important for me in any program related to this is that goals were set. Patient-identified goals. And you can just briefly look and see. You know, some of them were about, most of them were diets. One about alcohol. Smoking, again, is a key factor. So what did we do with year two? Well, I quickly learned from year one that we couldn't do any more interprofessional classes in person, and having Regina go to the clinic and kind of beg providers for patients wasn't effective. I think they became annoyed with us, quite honestly. So we have those 48 family medicine residents. So I used them, and I wanted this to be something that they learned to be important so that when they go out and practice, this might be something they would do. So we asked them to look at their patient panels. We asked them to identify patients with stage two hypertension, more than two readings, and they had to have been seen within the last 18 months. Year two, our intake systolic blood pressure, and our final, both systolic and diastolic, were lower. So this does work. When people finish the program, but that's the key. How did I capture data? Year one, Regina did phone calls and wrote it down and put it in an Excel spreadsheet. That quickly became clear that that wasn't gonna work. So I utilized Qualtrics Surveys, for those of you. It's a real easy platform. So I asked the residents to complete surveys at intake and then follow up, asked them to call patients twice a week, sometimes twice a month. Anything I could get, it became clear that I would take whatever I could get. And they put in a lot of rich information, things like, did you reach the patient? One of the things we learned, it's very easy to make a phone call. It's very difficult to reach the patient. Were you able to reach the patient? As you can see, look at the counts. A lot of phone calls were made without any futility. Did you use your book? I was very interested in that. Quite a few did and they really liked learning about diet. That was interesting. So again, nutrition is key to these programs. Do you have a goal? This makes me so proud. The majority of them did. I think that's important because this has gotta be something that patients manage, right? We can't fix it for them. We can give them medicine, but if they don't get engaged with their care and make lifestyle changes, it's not going to work. So barriers to reaching goals. This is just some qualitative feedback I wanted from my patients. Family had been ill, adopted a fourth puppy. That would make my blood pressure go up. I don't know why anyone would do that. Being tired, having a death in the family. Not really want to quit smoking quite right now. Tries to limit sodium, but good food is an obstacle. And boy, that's true in the South. They lose their blood pressure log. We call them and they say, oh, I'm so sorry, I don't have my blood pressure log right now. But I do have successes where people actually brought their cuff back to the clinic and a medication change was based on those recorded readings. Now, this is the key that I think is going to help me sustain this program. Remember I said we're a regional campus. We've recruited medical students. They actually reached out to me. They heard about the program. They're like, Dr. Friend, I'm really interested in this. Could we participate? Is there anything we could do? You know, medical students are enthused, right? They want to learn. And so I said, absolutely. You know what I want you to help me with are these phone calls. Because I think it'd be really important if you could talk to patients, learn how to do patient education, learn about the barriers to adhering. We've implemented meetings between the residents and the med students. Had some poor attendance from residents, but that's because they're very busy. And provided training sessions on our population health tool. We found that it's hard to engage residents again. Too much workload for them. 15 minute visits. They don't have time to do this kind of thing. It's great in theory, but in practice it just didn't work. And COVID, we've already heard about what COVID has done to all of the grantees. So obtaining blood pressure readings is very hard. As I indicated, we've tried all kinds of methods. A mobile app, paper logs, patient portal, calling and getting those readings, having patients bring them back in. Another challenge was the resident's attitude. Quite a few said, Dr. Friend, I don't think I'm gonna do this when I'm finished. And I think it's because it's just a lot of work. And they probably won't have the staff to administer it. So now I've kind of reached something that I think is in the middle of all the things I've learned. I still use residents to screen. I still use residents to enroll. But I now have another LPN health coach who is fabulous. And she helps enroll patients. She helps me keep track of folks. And she also helps make phone calls. We have determined that social isolation was the social determinant of health we wanted to assess because we heard from so many of our patients. You know, I didn't leave the house in the past year. I didn't leave the house in the past 18 months. And I thought, wow, no wonder. How can you control your blood pressure? So I'm getting the three minute sign. So let me go ahead. We have also reached out to a community partner, which is WellBama. This is a program that is offered to all faculty and staff at the university where they can get screenings and they can get free lifestyle classes. My team goes and stays there and we try to recruit folks from that group. Year three, you can see, we're still having noticeable decreases in blood pressures for people who do finish the project. We've recruited a webpage developer for folks who wanna read about our program on our webpage. And we obtained automatic blood pressure cuffs that were extra large because with the supply chain, that was a challenge. And we're not all, you know, a normal size adult. So ongoing issues, reaching folks, trying to get those critical blood pressures. But one thing I would like to say is that I do think we've initiated a cultural change in our residents. I know that the med students continue to get more and more involved with this. So I'm hoping that by including these learners before they develop pretty, you know, hard habits as older providers, no offense, but I'm hoping to anyone anywhere, I'm hoping that we can sustain these changes and really make hypertension diagnosis and treatment a priority. So thank you very much. Great. Thank you all to every grantee and all of the programs here and the CDC and ACPM. This was an enormous undertaking. This work is so incredibly important. This work is hopefully going to continue. And I think there's just tremendous things to learn through this work. So I wanted to open it up for an opportunity for anybody in the crowd if they had a specific question for either one particular grantee or just for any of them before maybe I start asking questions. So any questions? So, it's actually for everybody, I'm working, I'm with the AMA, I'm working on a project on Medicaid funding for SMBP services and devices, and I know where all of your states land, we've done a landscape assessment. But I also heard a lot about medication adherence, and I'm also working on policy around going straight to single pill combination, so you all addressed medication adherence, but my gut is you don't have included that people go straight to a single pill combo, and not individual pills, so I'm curious how you're looking at SPC, are you using the validated device listing, are you using validated devices, and just really talking a bit about if you're interested in the Medicaid project. PharmDs in every primary care clinic, and they are focusing on that. So, we are able to refer patients. We're able to refer patients. Grady. Grady Health System in Atlanta. PharmD, yes. Yeah. So, we do utilize PharmDs, and they focus on that one pill. So, I'm in North Carolina. We do have Medicaid coverage of SMBP, but you have to figure out how to get 14 readings into your EMR, which most of my patients can't do. So, you have to have MyChart, and then learn how to go into the little My Vital Signs. It's really pretty hard. I've actually stood over the shoulder of two patients, and I can't figure it out. So, we're muddling through that one. So, getting reimbursement is really, really hard. Exactly. Yeah, return on investment there, not so much. We are all on our calls, we all talk about validateBP.org. to tease out when they have an allergy, which one they're allergic to, then you have to prescribe both and have them try each. Like, it's not as easy as it sounds, but. Yes, and Cook County Health, hypertension is one of our focuses as far as a project, not a project, but as a HEDIS measure for our system. So we've implemented a number of programs, including our self-management BP program. But one of the things we did do system-wide was have a list. I'm sorry. I was just curious if there would be analysis across all of the grantees around success in the program and how many sessions people attended and if they were individual versus group-based sessions. I would be really curious to know if that was Yeah, I can just comment on sort of the evaluation of the grantee program. So there's some basic things that we asked of all of the grantees, including just basic process measures, the number of men you've engaged, the number of men you've referred, the number of men enrolled and completed, things like that. And then we asked them to track their blood pressure over time. So we will do some outcome measures based on control. Or if they don't achieve control, how much of a difference have we made? Have we at least simply reduced their blood pressure? So beyond some of those basic things, we'll look at specific measures that were unique to individual programs. And then there's a qualitative component. So based on the patient's experiences and the staff and faculty's experiences, we'll put that kind of interview package together as well. So we haven't teased out whether or not the sessions are individual or group, something we certainly can look at in retrospect. But there are a kind of common set of basic measures that we hope are not too untenable to kind of track over time so that, yes, we can compare programs to program. And then interestingly, we may develop a survey in the future just for patients across all of the five grantee programs to just ask, how did it go for you? What were the benefits? What are some of the challenges? So that we can look across that way as well. Lincoln again, Holly Viola. And we've already published a number of things about year one and year two. And we'll be publishing on year three here soon some qualitative interviews with patients and some numbers as well. So keep an eye out for that. Sorry, last question. It sounded to me like. about a hype app, but I wasn't sure what was. that we use are validated and when the patient came in we could upload the readings at home. And the other thing that Cook County Health did with the help of American Heart Association, we had those BP machine that we received that were bluetooth enabled and the patient would just everything would go to the iPad into our electronic health system. So we could actually see not just writing. Hi I'm Dr. Friend from UA. We developed an app called the Hype app and it's free in both Android and smartphone. We had a lot of success with it and then lost our programmer for the app and I don't know if any of you can believe this but apps are really expensive to develop. So you know it's there, the skeleton is there. I'm hoping to get some more interest and more funding you know to help with that. But in this population it was about 50 people would use it you know so and it didn't talk to our electronic health record because of HIPAA and privacy issues. But I think it has a lot of potential so thank you for asking about it. Okay so unfortunately we have another session starting with ACPM funded project on diabetes prevention. I encourage you to stay. We're going to have those three grantees come up and present their findings etc. So another round of applause to our hypertension grantees.

reducing hypertension

African-American men

Dr. Stacey Schott

grant program

uncontrolled hypertension

blood pressure monitoring

patient engagement

social determinants of health

positive impacts

health disparities

community health worker