We are so excited to see you here. I don't know how your day has been today, but for me it's been the kind of day that spending the afternoon talking about patient stories is a definite highlight. So I hope that you will enjoy what we are planning to share with you today. My name is Ayanna Buckner. I'm one of the faculty members with the ACPM Hypertension Demonstration Projects that focuses on African-American men. The title of today's session is Stories Hypertension Control is About People. I do have to tell you a little bit of a disclaimer. 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 U.S. Department of Health and Human Services. The views expressed in written conference materials or publications and by speakers and moderators like myself do not necessarily reflect the official policies of the Department of Health and Human Services, nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government. There are no disclosures or conflicts of interest from me or any of the other speakers that you'll hear from in this session. So what I'll do is I'll give you a brief overview of the project and then you'll hear from our pilot demonstration sites. There are four of them. They are Cook County Health System, Henry Ford Health System, Lincoln Community Health Center, and the University of Alabama. And then we'll have questions. Unfortunately two of our panelists have had some difficulties and aren't able to join us, so you will hear from the faculty members who are working with that with those projects. That means you'll hear from me again and you'll also hear from Dr. Stacey Schott. Briefly our learning objectives are at the end of this presentation. We hope that you'll be able to identify at least two roles that help recruit, screen, and refer patients into self-measured blood pressure monitoring programs in clinical settings. Describe at least two clinical support roles that provide optimal support to continuously engaged patients and maintaining and controlling their blood pressure. And describe at least one effective method of interaction between clinical support team and participants to address social needs, barriers, and barriers that impact effective hypertension control amongst marginalized populations. So as I mentioned, this work is funded through CDC as a part of a five-year cooperative agreement that ends this year. And our particular piece of that is around reducing hypertension among priority populations. There are several other pieces, but in the interest of time I won't read those. So a little bit about the project. It is funded from the Division of Heart Disease and Stroke Prevention at CDC. It's a multi-year initiative to support the implementation of innovative health systems and approaches to identify and address uncontrolled hypertension among black men ages 35 through 64. Grantees were selected through an RFP process and provided ongoing technical assistance from ACPM as well as from assigned faculty members. And that technical assistance is focused on prevention, detection, and control of the disease while breaking down systemic barriers to receiving optimal care and increasing equitable distribution of health resources. The goals of the demonstration project, and there are four, are to increase screening and testing of black males at high risk for hypertension, refer, enroll, and engage. And that engage is such an important part. To engage them in evidence-based self-measured blood pressure programs with clinical support and other related evidence-based lifestyle change programs. To address a social determinant of health that the grantees identified as a barrier to patient screening, care management, enrollment, or retention in the evidence-based lifestyle change or evidence-based self-measured blood pressure program with clinical support. And then lastly, but certainly not least, to collect and report data. That piece is also really important. This includes both process and outcome measures that reflect the experiences of enrolled men and assess the impact of SMBP and interventions taken during the project period. Our project timeline, our RFP was released in February 2019. Then in April, grantees were selected and finalized. And then our startup began in May 2019. The demonstration projects launched in July of 2019. And then a little thing called the COVID-19 pandemic happened in March 2020. That caused some issues with some of the project, well with all of the projects, having to make some changes to adapt to the pandemic. So you may hear a little bit about that in the presentations. I will caution you that we only have a short period of time to hear from our grantees, but we hope that we'll have a little bit of time after each presentation for Q&A and then more time at the end. So please do feel free to think about questions along the way and ask them. In July 2023, in just a few short months, the demonstration projects will end, excuse me, and our project sustainability and evaluation period will begin in August. As I mentioned, we have four demonstration sites, Cook County Health, Henry Ford Health, Lincoln Community Health Center and the University of Alabama at Tuscaloosa. I am Dr. Ayanna Buckner, one of the faculty members. We also have Dr. Prentice Taylor, wave at us please, and Dr. Stacey Schott, who you'll also hear from in a few minutes, in place of the University of Alabama at Tuscaloosa. And now you will hear from the demonstration sites. Thank you, Dr. Berkner. Good afternoon, everybody. My name is Chantelle Ting-Feng from Cook County Health in Chicago. So this project is truly relevant to Providence Hospital of Cook County because we provide healthcare to the underserved population in the south side of Chicago. This demonstration project takes place at SENSAC Health Clinic within Providence Hospital. Okay. Thank you so much. Thank you. Thank you. Providence Hospital and Training School is the first Black-owned and operated hospital in the United States. It was created in 1891 by Dr. Daniel Hale William, an African-American who was the first cardiologist to perform a successful open-heart surgery. During the first three years of the project, we were focusing on African-American men with uncontrolled hypertension age 35 to 64. We gave them a BP monitor and we taught them how to use the monitor to check their blood pressure at home. And we invite them to a hypertension class every month. During this year, we are expanding the project to include women who are friend, family, or partner of enrolled men. The monthly hypertension class is now open to all Senstack Clinic patients with hypertension. And starting next month, the class will be open to other patients of CCH clinics in the suburban county. We continue to provide on-site counseling. We refer patients to substance use disorder and we provide food vouchers for fresh fruits and vegetables. And we give them a voucher to go exercise at the Chicago Park District. This is the workflow at the Senstack Health Center. So those patients that we have in the project, they are identified during clinical encounter in the clinic. And if they have a systolic blood pressure of 140 or higher or a diastolic blood pressure of 90 or higher, they refer to the project. So when they arrive to the clinic, they check in with a clerk and then the medical assistant perform ambulatory intake using the seven simple tips to measure blood pressure precisely. So if the blood pressure is 140 over 90 or higher, the medical assistant will confirm the BP. How do we confirm the BP? What we do is that we let the patient rest for three to five minutes. We make sure that they empty the bladder. We make sure that we are using the correct cup size and we put the cup on the bare skin. Then we repeat the blood pressure three times. We average the three readings and we enter that in the EHR. Then the patient sees the provider and then the provider reviews the readings in the clinic and at home if the patient is coming for a follow-up and already been enrolled in the project. And then we assess for adherence. We perform medication reconciliation using guideline-directed medical therapy. And this year we are referring patients to remote patient monitoring. We perform education and we assess for system use. We reinforce smoking cessation and exercise. The medical assistant then perform encounter discharge activities, reinforce education. We use teach-back method with the patient. This year the community health worker is involved and will help patients navigate the social determinant of health. Our success. The project received a strong support from our health information department at Cook County. We were able to insert a hypertension action plan for our patient so that we would be able to tell them what to do if the blood pressure was high at home. We were also able to build a template for the hypertension class so that the patient can receive reminder calls for the class and they can have access to medical transportation. And this time around now we are able to actually enter home readings into our EHR. The other thing that's about this project is so good for Providence is that during our 2021 joint commission, this project was presented and we were able to successfully accredited for patient center medical home. We're going to show the video to about Providence Hospital and working with ACPM. Providence Hospital actually got its beginning when Emma Reynolds, an African American woman, was denied admission to all the nursing schools in the Chicago land. Providence serves predominantly an African American population and also serves as a safety net hospital in Cook County. We were able to enroll 125 participants over the past year and approximately 25 patients completed the study. The other thing that was very helpful was providing those patients with a blood pressure monitor that they use at home so they can actually check their blood pressure at home. When they come to the office, the nurse teach them how to use those monitors so that they can perform what we call self-measure blood pressure. In our system, our patient really, we focus on social determinants of health because sometimes they may lack medication, transportation to their appointment, maybe they don't have access to the food that they're supposed to eat. I've been working with Dr. Tempe for over 15 years, 16 years. She helps me a lot, you know, telling me to do certain stuff, you know, take your medication, make sure you take it, don't over, you know, back to salt and all that, you know, tablets and stuff, putting it up there. It's going to help, you know that it's going to help you in the long run, right? Yes, you know, yes, you keep me here. So this was one of our patients at the Providence Hospital. We have faced some challenges over the past few years. The thing is that some participants have difficulty mastering the technique of SMBP, and that's why we always ask them to bring the cuff in the office, we look at them, check their blood pressure, we make sure that they position the cuff correctly. The other thing that was a challenge is that we did not get any extra large cuff with the shipment of the monitor that we ordered. So this time around, we are ordering cuffs that will come with extra large cuff, small cuff so that the patient can have the right cuff for them. The other thing is that prospective participants have competing interests. Sometimes they don't have enough time to come to the office every four weeks to check their blood pressure because of the job, so they cannot really enroll. And the other thing is that they have some participants that enroll have issues with adhering to medical treatment. This demonstration project was very good for Providence because our patients appreciate the time that we took to teach them about hypertension because the other thing that we did during the project was focus on health literacy to make them understand hypertension as a disease so that they know what to expect when they check their blood pressure, so that they can understand what can affect their blood pressure. And we find out SMBP-motivated patients. It helps them reach the target and it gives them power in their health because when they come to the office, we look at the BP at home. We look at the BP in the office before we make treatment decisions so that they know that what they're doing at home is counting. Every third Friday, our staff meeting, we discuss hypertension control. We talk about what else we can do to make sure that we're getting more patients at target and that we're keeping them at target. This is a graph to illustrate how many men identify in 2020, 2021, and 2022. This one here is by year. We can see that in 2020, we have less patients coming to the office because of the pandemic. But then in 2021, we were reaching 38%. In 2022, we were close to 50%. So the participant, when they complete the program, for them to complete the program, they have to have a BP of 130 over 80 at three consecutive clinic visits. Then they get a certificate of completion. If they don't reach the target and let's say they're not able to come back, we can give them a certificate of participation. We also give them a t-shirt. This is one of our patients with a nurse practitioner that sees those enrolled participants. She was in the project, worked on the project since 2019. This is what our patients are saying about the project. They feel that we care for them and they want to get their blood pressure at target. Next step for CCH. This demonstration project is the foundation for us to build a remote patient monitoring. So this time around, IT is helping us use device that's going to enable us to have the BP directly being uploaded into our EHR. We are hoping that when we do this, it's going to improve outcome. And then when it's improved outcome, it may increase our HADES payment, bonus payment. And then we're hoping that this will support the long-term economic growth of the project when the grants fund end within CCH. We are extremely thankful to Dr. Berkner, Ms. Anita Balan, Ms. Gay, and then to our CDC staff, Dr. Presley Cantrell, Ms. Barkley, and Ms. Ahmed. And I'm grateful to Dr. Turner and Ms. Egnogwe and Mr. Morris Brown. Thank you. Are there any questions for Dr. Berkner? We have time for one. And we'll have a more robust Q&A at the end. Any questions? Okay. We'll think of some. We'll hear from the University of Tuscaloosa. We'll hear from Dr. Berkner. We are a large academic medical center that serves the city of Detroit. have been able to do in terms of the grant. So at Henry Ford Health, we continually strive to develop innovative and culturally responsive approaches to ensure that our very diverse populations that we serve have the best possible outcome. So we're involved in a lot of quality improvement projects, particularly with our communities. We know there are disparities in blood pressure control, particularly with our African-American men, and more particularly, the younger population. Our older population, 65 and above, is actually in pretty good control. But our population within the age range of 35 to 64, which the grant covers, we noticed a huge disparity there with control. So that led us to create the program that is the grant-funded project that we call the Express Blood Pressure Program. So this is a multifaceted and multidisciplinary team with data analytics support as well, approach to improve hypertension control amongst African-American adult males within the age range of 35 to 64, who are known to have uncontrolled blood pressure. And we're trying to do this through repeated, brief, focused initial assessment, and then follow-up visits. We wanted to create a synergy between a program that we actually already had going called our RRM Blood Pressure Recheck Program. We have nurses that are trained specifically on an algorithm. And they've been doing this since 2013 to be able to adjust patients' medications based on their level of control. So as long as they need to follow that particular algorithm. And we were able to integrate that with another program that we had more recently running with our pharmacists, embedded pharmacists. And they were working particularly with hypertension and COPD patients. So we kind of married the two programs in a way, and then started the focus on hypertension with both programs. In addition to the RNs and pharmacists, we also had medical assistants involved, community health workers brought on. And we wanted to leverage the strengths and complement their activities. So we wanted to match our patients to services based on their needs, comorbidities, and their medication regimen, the complexity of that, as well as their overall health situation. Our real goal, and why we called it EXPRESS, was to achieve blood pressure control within roughly about eight weeks. So we wanted to really have a quick turnaround with this program. We wanted to engage our patients in home blood pressure monitoring, as was mentioned earlier. That's an important facet of our program, is distributing and teaching patients on home blood pressure monitoring and sharing their results with us. We wanted to offer patients flexibility as well, hours, quick visits, as well as virtual appointments. We wanted to make sure that we were meeting our patients' needs, particularly, as everybody knows with COVID, that kind of blew things out of the water with a lot of our activities that were in person. So virtual appointments became critical. We're monitoring med adherence, making sure patients are actually taking the meds that are being prescribed to them. And BP control and patient satisfaction was also measured as a result of this. And we're also assessing, addressing, and supporting social determinants of health needs. So this is a quick workflow diagram of our EXPRESS BP program that includes the inclusion criteria, African-American male between the ages of 35 to 64. Very important, also, that the patient was seen by their PCP within the last six months. We didn't want patients coming in that hadn't been seen by their PCP, or at least by one of the residents in the clinic within that time frame. And their last blood pressure was greater than 140 over greater than 90. So we did this, as I should have mentioned earlier, as a pilot program at two of our sites that had a large number of patients that fit the inclusion criteria. So then, for those patients that met criteria, a referral and patient outreach was done. Provider was aware that the patient was going to be outreached to. We have analytics working on this and giving us a list of the patients that fit that criteria. And then we started with the patient outreach, which initially involved the pharmacists themselves, the medical assistants, and, to a lesser extent, a pharmacy intern that was working with our pharmacists. Later on, we added the community health worker, which was a huge boon to that process. The patient was scheduled with either the pharmacist or the nurse, depending on their particular situation. And I'll show you that workflow in a second. 15-minute appointments were scheduled. The visit was documented. And then whatever follow-up needs. If the patient's blood pressure was not in control, they would schedule another visit. If it was in control, then they would be discharged back to their PCP. Then this is the multidisciplinary roles of the various individuals involved and various disciplines involved. The embedded pharmacist, the nurse, the MA. And then, more recently, in 2021, we added on case management. Then in 2022, the community health worker. And then just this last year, within the last couple of months, we've identified and added an RD student onto our team as well. So the pharmacist and the nurse are basically involved with the assessment of the patient, revising their medications as necessary, checking their adherence, as well as doing education, lifestyle coaching, and distributing home blood pressure monitors, as well as doing a food insecurity survey, if that's not already done. And that is part of our assessment in EPIC. The medical assistant, as you can see, did a number of the similar things. Not the medication piece, of course, but a number of similar things. So the point of this chart, too, is to show that while there are some core things that each of these disciplines do, some things do overlap. Our case manager was pretty much involved with referrals and supporting the SDOH, particularly food insecurity. Then our community health worker was brought on, who is also an African-American male within the age range and also hypertensive. And so he was doing some more personalized outreach to patients that we were really having a hard time getting a hold of. So he was very effective in being able to contact these patients and have more in-depth conversation with them about the importance of blood pressure control, ramifications of poor control, and getting patients into the program. So that was, again, a real boon to our program. And then the dietetics student, she's just starting. She's actually going to see patients specifically to teach the DASH diet, as well as to provide a lifestyle presentation for our physicians and residents and support team members. I'm not going to go through all this. Don't get scared. But this is basically our workflow program for the Express Blood Pressure Program. So the physician initiates the referral. But many of these patients we identify through analytics in the list that's generated anyway. So then, depending on if the patient meets those various criteria of complexity, either number of comorbidities that he has and or the number of medications he is on, then that patient will either go to see the pharmacist for the more complex patients or to the nurse for those patients who have less complex needs, such as a patient who's maybe been more recently diagnosed is only on one medicine, and then just to have more follow-up goal setting and patient education needs. So the patients generally are less complex with the nurse. Then, again, the case manager role, when we have patients who do score positively on our food insecurity assessment or present with some other SDOH needs. And we haven't added the community health worker onto this yet, but we will. Some of our successes are patient impact. The control rate of 52% for enrolled patients in the target population has been reached since we started back in 2019. Of course, that does mean 48% are not in control. So that's on our challenges list as well. Patients enrolled in ExpressBP have had a better sustained blood pressure control and medication adherence compared with some of our non-ExpressBP clinics, and we have some data to support that. And then our team impact. We do have a very, I'm sorry, our patient satisfaction rates are also very high for ExpressBP, to a point where we even stopped handing out satisfaction forms anymore because we had such high rates of satisfaction, we felt like it was getting to be a redundant exercise. As far as our team impact, our clinical teams are very engaged. Again, recently added an RD student as well as an MPH student. And our pharmacists have remained very stable as have our nurses. So fortunately, we haven't had too much trouble with staff turnover in those roles. And our physicians are very, very supportive of this program as well and think that they would not know what to do if it wasn't available. Then our CHW also, that role has been developed to enhance outreach efforts and get patients involved with things such as utilizing a pillbox so that they remember to take their medications, which in turn will help with our adherence, and doing food insecurity assessments as well. So the CHW has really played an integral role in that as well. And then we did provider surveys to offer insights into the barriers into hypertension treatment. So what the physicians were seeing as part of their barriers and things of not being able to get patients into better control and what we could do to help. We did create some comprehensive and sustainable patient educational materials that can be online so they can be adjusted as recommendations change. We did implement AOBP devices at all of our clinics to improve accuracy. Staff was trained on it. We did a pilot on that, showed that the AOBP with the averaging after three readings really did make a difference in improving control rates. So we got the OK to go ahead and distribute those at all sites. And then also Henry Ford, as a success, was a top finalist for the Bernard J. Tyson National Award for the Pursuit of Healthcare Equity by the Joint Commission and Kaiser. So the patient video I'm going to show, this is a patient. His name is Mark Jackson. He's a very good example of why the ExpressBP program is really important. He was identified by that outreach, by that list that I mentioned, with a blood pressure reading of 179 over 109 at his index visit. So he was seen by the pharmacist. Her name's Octavia. He'll refer to her. And she assessed that he was not taking his medication. So big reason as to why his blood pressure was not controlled, but a very common scenario, I'm sure, for many of you. It took two and a half months to achieve a goal, being seen every two to four weeks with two consecutive blood pressure readings of less than 130 over 80. And he remained in the program voluntarily. He asked to continue to be seen for an additional month for two more visits to ensure that he maintained control. He had built up such a good rapport with the clinical pharmacist. And with her support, he was able to resolve his adherence issues, obtain the needed education that he was lacking, and get to goal. So I need to minimize this. Oh, I need something here. I think mine had to be put up separately. Yeah. Oh, you're good. My name is Mark Jackson. And I've been working with Itavia for about three months. And one of the benefits that I guess it's not showing up. guarantee it's not going to work. But working with Octavia, as good pertains to my health, is trying to get my blood pressure under control. Seeing her every other week or every three or four weeks, just looking at my blood pressure and her making adjustments to my medicine, or just trying something, trying another medicine to get my blood pressure under control, getting helpful hints from her as far as diet and health and exercise and all that kind of stuff. So it was a benefit to me, and I hope that other people take advantage of this wonderful opportunity. Thank you. It was short but sweet. He was very nervous during that taping. But basically, the takeaway from that is that he was very nervous, but the main takeaway was that he did come for his repeated visits. He basically followed the program as it was intended to be, short visits every couple of weeks, and had interactions with Octavia, the pharmacist, in between his visits to the point where he started adhering to his meds, understood the importance of taking his meds, and then got into control and continued up with a couple of additional visits to make sure it stayed that way. So with that, this is our team. We've had some changes with our team, particularly, like I said, with our community health worker and adding on an RD student. So that's been a big help. And that would be my presentation, unless you have any additional questions. And a big thank you also to our team from ACPM, Dr. Taylor in the back of the room, Anita Balin, and the CDC. There is a delegate, oh, oh, yeah, oh, okay. Yeah, I'll just summarize, so there was a question from the audience about expressing interest in pharmacists and RNs making adjustments, and that that seems unique, and so she wanted some just additional thoughts about that. Is that good enough? Go ahead, thank you. Yeah, actually, I think I had mentioned that the RN program had been going on for a while. We actually launched that back in 2013, so this is actually its 10th year. It is unique in the sense that we created a delegated authority arrangement with our primary care physicians, so that based on the algorithm, and the nurses can only use the algorithm that was created for them. They cannot initiate meds, they can't discontinue meds, but they can adjust meds within the range of the algorithm that was created, and there are only certain classifications of medications on that particular algorithm, so they are allowed to do that within the confines of that. The pharmacists, they also have a delegated authority arrangement. They have a little bit more leverage because of their much more vast knowledge of pharmaceuticals, obviously being pharmacists, that they can initiate as well as discontinue medications, and the leverage that they have with the medications is a little more broad, but it is under a delegated authority arrangement, and that's reviewed every year and renewed, and so we make sure that everything is still up to date, and that everybody's still in agreement with that, but it really was to offload a lot of the patients that really didn't necessarily need to be seen by the physician that were relatively straightforward, even though they may have been in poor control, like this gentleman here. He wasn't taking his meds, so that's a big reason as to why his blood pressure was in poor control. Did that answer your question? Okay. OK. And you may recall at the start of the presentation, I mentioned that two of our panelists unfortunately couldn't join us. So I will be giving the presentation that Dr. Holly Biola, who's Chief of Family Medicine at Lincoln Community Health Center, was planning to give. So you can just pretend that I'm her. This is a little brief, and there's a lot of stuff here. So I'll try to go through it in a way that's helpful. But for their project flowchart, they identify African-American males who've got the systolic blood pressure of 160 or a diastolic of 100 via report from their EHR. And they assign patients to students. They get the blood pressure cuff to the patients, educate patients on hypertension, ask them about their social determinant of health needs, and work with the patient to make a health-related goal. Then they get BP readings. And they, meaning the students, get the blood pressure readings from the patients and then, with the faculty, help to reconnect the patient to resources at the Lincoln Community Health Center. So during the second year of this project, because of the COVID-19 pandemic, Dr. Biola and her team shifted to doing virtual classes. Before the pandemic, they actually met in person with their patients, but shifted to a virtual approach. As well as with their work with their students, they shifted because of that. And so they assigned undergrad, nurse practitioner, and medical students, 10 to 20 patients each, to contact them by phone and promote SMBP. Oh, and prior to that, they train the students on privacy standards, basic hypertension education, and how to actually conduct or how to use the SMBP monitors. In the third year, because they were working in the second year with students at Duke, so in the third year, they started working with students at North Carolina Central University. And they collaborated with the North Carolina Central University Nursing School, using the same format as the Duke classes. But at that point, because it was year three, the classes were in person. And so they identified four NCCU students and four Duke students who were also brought on and paid a stipend, actually a pretty good hourly rate, to help lead the project. So most of the students were working as a part of their class, but the leaders, because they were doing some extra work helping to coordinate the students, they received some funds. And then patients who engaged with the student were more likely to return for primary care continuity visits after the calls. As you can imagine, particularly during the early parts of the pandemic, people were dealing with a lot of social isolation. And one of the things that they learned through this project was that some patients really enjoy talking to the students. And so they were able to really build upon that as they worked through the project. In year four, they are continuing telephonic outreach to patients. The Duke students in fall of 2022 called 345 black male and female patients. And the NCCU nursing school students this spring so far have called 190 patients for a total of 535. So pretty, pretty impressive. So they've improved health for patients overall. Patients from, in terms of patients whose BP was under control, it increased from 59.3% to 64.7. And the patient had some really great success stories. They've had warm, enthusiastic outreach from students that helps to spread goodwill in the community, to the point that patients really expressed about how they felt really cared for. And they even had patients telling them, we feel like this community health center is for us, which was, I think, one of the biggest compliments that anyone could have. Students learned motivational interviewing skills and were able to practice them in real time. And some students even changed their own health behaviors. So we'll now hear a video about Social Determinant of Health Needs from a former student who was a team lead with the project. And very proudly, he's actually joined the staff of Lincoln. So I think they did something right with this project. Hello, my name is Daniel Townsell. I'm a nurse practitioner attorney. And I joined the Severe Hypertension Outreach Program as a nurse practitioner student at Duke. My contribution was to help design an intervention to refer patients to a team of social workers and attorneys and as a medical legal partnership to address health care issues that require legal intervention. Health care issues requiring legal intervention for resolution, I refer to as health harming legal needs. In our intervention, we identified four of these. That is the loss of Medicaid, loss of SNAP, loss of disability, as well as immigration issues. What's most remarkable about doing this work as a student and now working as a provider at Lincoln is that I see how hard it is to identify or address these issues in a 15-minute clinic visit. At some point, I would be interested in a health justice clinic where we could refer patients with complex social issues to a clinic where we have the bandwidth to discuss these issues and build a foundation for better health outcomes. And I will tell you that if they do that, we are absolutely taking credit for it for this demonstration project. This is one of our priorities. Hello, my name is Dr. De'Ange. Oops, why is this not working? OK, here we are. And here's another video from another. I've always been interested in working with underserved populations and mitigating health disparities. So I was eager to begin volunteering and eventually working on the Severe Hypertension Outreach Project at Lincoln. Being able to make outreach calls to patients has improved my soft skills and communication skills, which is important for me because I feel I've already gotten a unique experience that will benefit me in medical school and beyond so that I can become a great physician. I've also been able to familiarize myself with how a community-based intervention can be run and its impact on patient care. My favorite part about talking to patients in this program is when they express their gratitude for us looking out for them. And I can really tell that so many appreciate the extra checkups from the Lincoln team. It seems like our outreach helps build better relationships between the patients and Lincoln as well. Additionally, this project has helped me understand the importance of seeing a patient holistically. So not only engaging with them in the clinic to meet their medical needs, but meeting their social and preventative needs outside of the clinic as well. Overall, I look forward to continuing to work towards closing the gap on health disparities in my medical career. And Ms. Gaines has been accepted to medical school. So we are excited that she is working with Dr. Biola on this project. And we are trying to recruit her to become a preventive medicine physician. Very actively, actually, trying to recruit her. So Dr. Biola would like to express thanks to ACPM, to Dr. Granger, who is one of the faculty members at the Duke School of Nursing for spearheading the Bass Connections program and mentoring countless Duke students through publications. I'd also like to thank the now more than 30 Duke undergraduate and graduate students who've been involved in the project. And thanks also to Duke's Bass Connections model for helping them to work with students in this innovative way. We'd like to also thank Dana Carthron and Lily Chen of North Carolina. I'm sorry, Dr. Dana Carthron and Lily Chen of North Carolina Central University for their support in forming new relationships with Lincoln and also mentoring students through the project. We'd also like to thank Dr. Veronica Ray at Lincoln for her generous gift of the Lincoln Legacy Award, which bought low-sodium snacks and produce for the in-person classes that the project was able to do prior to COVID and helping to make sure that blood pressure monitors were available to all who needed them, even if they didn't fit into the grant. Because in the beginning, our project was only for African-American males. We've since expanded it to African-American females. But the Lincoln team really decided to use some additional funds to open it up to all of their patients. So it's important for them to acknowledge the folks who funded it. But we also take a little bit of credit for that, too. Yeah, thanks for laughing at my joke. And that is all. Any questions? I think Dr. Biola may actually make it to the conference, as well as Ms. Gaines, who's the future MD. So if they make it here by the time we have Q&A, we'll allow them to answer. But if not, I will do my best to answer on her behalf. And now, we will have the University of Alabama at Tuscaloosa. Oh, thank you. Hi, good afternoon. My name is Stacey Schott. I'm a preventive cardiologist at Johns Hopkins. And I've been the faculty advisor for the University of Alabama's program. And you're getting me today instead of Dr. Friend. So I will do my best to present Dr. Friend's great work in the best way I can. So today, I'm going to tell you stories. Today, we're talking about stories about people involved in hypertension control. And the story about University of Alabama is going to lean heavily on the learners within the system. So this is an academic medical center in Tuscaloosa. There is a 48-count family medicine resident at the program. There's 32 primary care track medical students. And the population they serve is over 45,000. Of those, 24% have hypertension. And of these, 46% are black or African-American. And the hypertension control rate in that population is less than 50%. So the program, although the patient and the participant is the most important part of the program, this slide is going to show you the interesting interrelationships on campus and the system that we've built clinically to help provide good hypertension care for those participants. So it starts out with a population health tool. So we've engaged the IT team to identify hypertensive men. And quarterly, they generate a hypertension registry. Any men within the catchment area that have blood pressures 140 over 90 and have had a visit within the last year in that system get funneled to the residents at the family medicine clinic. And they will get a list of their individual patients that show which men have hypertension. On that list, the residents will then screen and find potential participants. When they reach out to them and bring them into the clinic, they'll talk to them about the program and refer them into it. And in addition, that list is given to a person in the position of hypertension care coordinator. This is kind of the central person at the hub of this program who reaches out in a different fashion to other supportive people like social work, case management, and students. So the hypertension care manager will also screen that list and refer people into the program. Once men are accepted into the program, they get teaching on how to manage their blood pressure, on how to use the blood pressure cuff that is given to them. They get a wonderful education booklet that was made at the University of Alabama that has diet, lifestyle counseling. And then part of their intake and part of the social driver of health, trying to understand the social drivers of health in this population, they asked about the patient's access to technology. Do they have a smartphone? Do they have computer or internet access? And they actually found that about 90% of the population does. And so based on that, they had developed and yet further developed an app called the Hype app, which includes a lot of educational materials that are given in the handbooklet, recipes, a blood pressure tracking device on that app as well. And then the participants are also welcome to do in-person hypertension training and classes. And they involve the pharmacist, involves nutrition, social work, coaches from the diabetic counseling program as well. And then here we see where the medical students come in. So the medical students are certainly involved in the lifestyle classes. But the key component of this project is the medical student outreach. So the medical students are assigned. One or two students assigned to each participant. And they call bi-monthly. They'll try to arrange a time to contact the participant, go over lifestyle counseling, help them with a particular lifestyle goal that they've chosen. They will collect blood pressures and then put that data back into our database so that we can continue to track blood pressures over time. And a more unique aspect of the program in the past year or so has been trying to use a tool called Prepare. So this is a national standardized 25 question tool that tries to capture social drivers of health. And so the students have been trying to get some of that data on the phone. And then also in the clinic, they've been trying to get some of that data. And then that's going to feed back automatically into the population health tool. And they have the ability to then overlay social determinants or social drivers of health with their hypertension registry and really see where in the community that people are most impacted and by what social drivers of health and where the biggest needs are. That's also been a wonderful kind of advancement in sustaining the focus on social drivers of health within the University of Alabama institution at large. So the patients will continue in this program for about three months. And then they have the option to either continue longer than that or complete the program. So that's the basic structure. Successes of the program has been, as I mentioned, this population health IT software and the ability to overlay the social determinants of health. They've had a really high enrollment rate. So when patients are offered this program, about 98% say yes and 98% enroll, which has been wonderful. One of the challenges then is keeping patients enrolled. But they're most often quite excited about this. I think University of Alabama has done a really good job about centralizing care over this three-year period, building a team-based care, and then consolidating that into this hypertension care manager position whose sole focus is to address the needs of hypertensive men. And the hypertension care manager also oversees the medical students in the program, social work students that are in the program, and interacts with the residents who end up managing blood pressure medications and seeing the patients in clinic. The hypertension care manager also has built community partnerships. And then once we gather the social needs on these participants, links them to partners in the community and university-based resources. So two really good partnerships that have come out of this project work has been just linking into something at the university itself, a wellness initiative called Wellbama, and engaging the resources there, and then a partnership with a group called 100 Black Men of West Alabama. So this has been unique because initially, we engaged the participants in the program in a loneliness scale and found if there were men that felt socially isolated or lonely, then they would be the ones to be referred to the 100 Black Men Partnership and Mentorship Program. But it became a two-way street where the 100 Black Men participants, who are already mentors, are now interested in becoming participants in the hypertension program. So there's a nice kind of back and forth that has developed here to improve their health as well. The big success of the program has really been the sustainability. Because this is deeply embedded in an academic system, they're able to engage a lot of resources that will be there over the long term. For example, medical students, residents, graduate students are involved in the program, social work students as well. And so this is exciting because we're engaging them in a kind of socially conscious training, exposing them to the field of preventive medicine and public health, and helping them become the next kind of generation of hypertension prevention leaders. And then really positively, the medical students that engage in this program are in their third and fourth year. And they typically receive academic credit for this. And they can also use this as a quality improvement initiative. OK. So I think there are some slides missing. But we are going to hear primarily from medical students. I'm here with Tyler Newell, who is a rising fourth year medical student at the University of Alabama School of Medicine. He has come on board in the past couple of months to assist us with this study. And he's graciously given us time to talk a little bit more about his experience. And so yeah, let's get started. Tyler, could you tell me a little bit more about your role in this project? Sure. So mostly what I do is I follow up with the patients who are enrolled in the study every two weeks. I give them a phone call to check in on if they've been tracking their blood pressure, if they've had any problems using their blood pressure cuff, getting or taking their medications. And then I'm able to report all of that information and report back. And then also, as I've been seeing patients in clinic, I've had the opportunity to recruit a patient of my own for the study as well. Yes, that's so great. What are some of the things that you've learned while being on this project? Yeah, I think it's been a really good learning experience. In medical school, we're often taught about non-pharmacologic interventions for hypertension, like exercise and dietary changes. But I thought it was really interesting to see how something like self-measuring blood pressure can improve blood pressure control. And another thing that I've learned, too, or I've been able to improve my skills just with counseling patients. We're often able to talk about their goals every other week. And then when I follow up with them, I'm able to ask if they were able to meet those goals and talk about things that they can try if they weren't able to meet those goals. Hi there. My name is Cyrus Baramji, and I'm a third year medical student. I wanted to get involved with the self-monitoring blood pressure study, given the direct and positive impacts that can be made with this project. In other words, as a student on clinical rotations, it is striking to witness how prevalent the diagnosis of hypertension is among the community, across the United States, and its devastating long-term consequences. Furthermore, it is empowering to actively take part in the well-being of the research participants by keeping them engaged with their health, promoting a preventative health mindset, and allowing them to live the life they hope to live by mitigating life-changing sequelae from chronic hypertension. It is a privilege to be a part of this project, as it has allowed me to realize as a future physician how both advocacy and a patient's proactivity can make simple yet substantial improvements in one's health and health outcomes. Thank you. We were missing a slide about some of the feedback from the students. But when they're coming through their community health rotation, they get the opportunity to kind of longitudinally become involved in this program. And a lot of them have a lot of positive feedback about how it's increasing their ability to manage lifestyle changes, to build relationships with patients. And it's been really fantastic, because the students are kind of the cornerstone of contact with the patients throughout the program. And we have seen their feedback. And some of the notes that they take during these conversations have been exceptionally telling about the challenges that our patients have, including the inability to focus on their own hypertension care or own health, because they're taking care of another family member, they have other challenges in their life, or that they don't perceive hypertension to be of that much importance to them. They still don't understand the potential long-term impact of uncontrolled hypertension. So the students' work has been very, very rich in understanding what is working in the program and what isn't. And then the challenges that the students have had in contacting the patients. Although about 90% of this population has access to the smartphone or the app or a computer, it's difficult to reach them on the telephone. So even though they set up a predetermined time to talk and to go through counseling and to get the blood pressure measurements, we found that sometimes when the students call, they'll reach the patient, but the patient doesn't have the blood pressure data handy. So that leads us to believe that we need to explore, like other programs are exploring, the ability to get data from the blood pressure cuff directly into the EMR. Because we have this nice technology where we can collect social determinants and then overlap that with our demographic data for patients and develop nice community maps of where the highest needs are. But we're having trouble getting the numbers of blood pressures at home. So the students have been a really, really critical piece in understanding what is working and what isn't, but just by getting their feedback when they have discussions with patients. So that qualitative component has been incredibly helpful. All right. Thank you very much. So we hope that in the presentations, you have seen different perspectives of stories. That's something that was very important to us as we planned this session. And so are there any general questions? Yes. Yes, so the question was, is the funding for this program from a CDC grant? And ACPM has a cooperative agreement with CDC. And so it funds, I think, from my slides, seven different areas, is that correct? I can go back to my original slide. But this demonstration project is one of a suite of things that ACPM provides as a part of that cooperative agreement. Sure. So, the question is, she was wondering if, or the question was if we have considered looking at integrating with projects, with Medicaid funding. Yes. And we have not done that to our knowledge, but I think that's a great question. Yes. Another question. Thank you. So I'll try to summarize the question in case people weren't able to hear it. But the question from a budding innovation guru in preventive medicine is how we are building upon the lessons learned from the COVID-19 pandemic and continuing, or if the projects are continuing, virtual service provision as there are barriers that patients can face with coming to the clinic in person. Was that summary OK? OK, very good. Would any of our, yes. And I will answer from Lincoln's perspective at the end. Got it. Oh, and so then there was an add-on question about EHR integration. Is that okay? Okay. Yes, so what we learned at Cook County Health during the pandemic was that patients were not able to get to the clinic. That's why we started doing remote patient monitoring at the beginning, but it was kind of very expensive to do, having those data uploaded into the system. That's why with this year grant fund, we are trying to expand the remote patient monitoring just for own patient with uncontrolled hypertension, maybe a patient that just had a stroke. And the way that we are doing it, our health information system needs to be involved because we have to have like a billing code in place for that. And then we have to have a Bluetooth enabled BP monitor so that when they check the blood pressure at home, we can have those uploaded into the EHR. And you're right. And that way we can just call the patient at home, review them. That's why it's so important to really teach them how to do SMBP technique, right? Because if they don't do it correctly, we're going to over medicate the patient. So really teaching is important. And then after we know that they're doing the right thing, we can just call them, upload, look at the readings at home and then make a treatment intensification. Great question. And with the COVID pandemic, we did basically switch overnight as many organizations, if not all did from in-person to virtual. So we have a very strong virtual presence within not just this particular program, but within our system as well. And we really promote virtual visits as an entire way to gain better access to healthcare. It's much more convenient. People don't have to drive, et cetera. So a lot of these visits for specifically these blood pressure, for this blood pressure express BP program have converted over to virtual so that we can engage more patients, like I said, improve access and then get the patients seen more quickly in between in-person visits. We would like them to be seen in person, at least initially to do an assessment, but then follow up after that until discharge time. Some patients have gone entirely virtual and never come back into the office at that point, unless there was something else going on that they needed to be seen. But we also encourage our patients to utilize the MyChart option in Epic to report their blood pressure readings. There's a mechanism that you can download your readings or record your readings in Epic, send them to your provider's office, and then so that way it reduces some of the paper scrambling back and forth. Although we still have patients that prefer to use paper and want to use a paper log, that's fine. They can still send those in, fax them in, or call them in if they're much more inclined to do that. So then one other piece of technology that we're just starting to utilize now or we're experimenting with, I should say, is called Cipher Health. I don't know if that's familiar to anybody, but that's a program where, particularly for our initial outreach to patients, rather than having to rely on phone calls and phone tag back and forth, it's a text messaging option where patients will get, based on the list, if we get patients who are eligible and meet the criteria for the program, they will get a scripted text message sent out to them. And then if they call back, then there's also prompts and a script that go along with the callback so that we can try to engage more patients through automated means rather than relying on phone calls and letters, which letters tend to wind up in the garbage and phone calls tend to wind up on voicemail or never returned. So we're actually planning to launch that later this month. So just a comment on what University of Alabama experienced during the COVID pandemic. They initially started these hypertension classes in person and that was well attended. People liked that. And then they tried to revert to virtual, you know, on Zoom, having the hypertension classes. And unfortunately they had some technical difficulties and people kind of breaking in. So a security issue actually during Zoom. So that kind of challenged them and people didn't want to continue in that fashion. So now they're back to the in-person and part of that is because it's seemingly, and we found that there was a need for sort of camaraderie and getting the patients together in an initial visit when they're kind of getting into the program during intake seems to build a little more camaraderie rather than just being isolated in the virtual world. So that's one particular challenge. The University of Alabama also had a wonderful app. So they tried to move a lot of this onto a virtual platform where they were collecting blood pressure and giving that clinical support through the app because this population actually 90% has access to the internet or smartphone. The app was well liked, but then it became expensive. So it's not, the app is no longer a viable platform for them to keep moving forward because of the cost, the maintenance and the cost. So although that could help, that's going to be a challenge for them in the future, just funding that and having the infrastructure to continually update that. So those have been some technology challenges. And now they're starting to think about the texting option. So the phone call, most patients are saying, yes, please call me and call me on this date. And sometimes that's successful and sometimes it isn't. And so we're thinking we're having an engagement problem. People sign up, they want to be in the program, and then it's hard to keep them engaged over time. So we're looking at other options. Would text messaging be helpful? The thing that I think we've learned is that people communicate differently. People's health literacy is different. People's wish to engage is different. They've also explored the platform, the MyChart kind of platform, and some patients did not like that and didn't want to be contacted in that manner as well. So I think the moral of our story is that having multiple options and building a system that can customize to the particular needs, communication needs of that patient will hopefully be most successful because it certainly isn't one size fits all. And again, you may recall that I'm representing Lincoln Community Health Center and that Lincoln engaged with both Duke and North Carolina Central University. And one of the beautiful things about that is that by really fostering these great partnerships with these institutions through their academic programs, it does really provide a platform to continue to build upon the approach that they built in virtually, and so they plan to continue that. vitals at Cook County Health, it took us months to figure out how to document those, right? And now we are in the stage where you can actually document those. And it's true that with the new system that they're doing with hypertension now, we will get credit if the BP is controlled at home, even if it's not controlled in the office. And then we want to make sure for the HADES payment that we're getting patients back in the office and that we're getting readings, even home readings, if you're able to document, you get credit for that. So now the measure that we do, that the patient does at home and we document, those are called patient self-reported measurement. We use CHERNA, so we don't have APICS, so that's different. With CHERNA, you can really work with the system and do what you need to be done. With APICS, it's a little bit more complicated. And now, so for the remote patient monitoring, those vitals will be coming on the patient self, anyway, it's different. We have self-reported and we have self-measure. Self-reported is what they're telling me that they did, it's what the machine is telling me that they did at home. Self-measure will be the one that is connected to the system and being directly uploaded into the EHR. And even that step, it took us a lot of time to figure out how to do it, because it got to be, the one that you document in the office, you need a date. You cannot just put a date out there, BP from home is this. You can put that in your notes, but to get credit, it got to be there with a date, not time. We were able to eliminate the time because it takes time. But the one at home, you get the data as they're doing the measurement at home. So if you call the patient for telehealth, let's say today, and they measure yesterday, the data will be there with the date from yesterday. So it comes with a date and time stamp, but the one that we documented in the office, we don't have a time stamp, but we have a date. Because we have CERN now, we can work with that, but it takes time to figure out how to do it. In our system, we don't have the student involved. So we have a nurse practitioner and a physician that sees the patient. So for the first, for the past three years, we were using an app called BP2 Light, where they're having those monitor that we were using. They will come in, you just click and connect, because the patient was assigned a number. So it recognized the monitor and everything was obliterated in that system. Not in our EHR, that's different. So we were able to get those data in. But for the student... For the titration programs, where we have the pharmacist and the nurse involved, typically what happens then is when we get those readings from home, first of all, we created a competency so that the patient, particularly for these two pilot sites that I mentioned where the program is at, the patient had to meet the competency requirements to ensure that we would even accept their home blood pressure readings, because not everybody can do it. Most patients are fine, but there are some that just cannot, and they don't have somebody else that can help them out with it. But for those that we did accept, where those vital sign readings go is in... And we're on Epic, and they go into the vital sign section of Epic, and that's where they have to be entered in order for... To be counted towards quality measures. So that's where they go when they come in, and typically it will either be the nurse, the pharmacist, or the medical assistant will record those readings when we get them from the patient. Does that answer your question from that perspective? Okay. Did you want to... Sure. Dr. Schaub? So at University of Alabama, where they're using a student model for most of the outreach, the students call, and then they're documenting reported blood pressures from the patient into Qualtrics. So just kind of like an... It's like an Excel-based kind of data collection system. And then there's a graduate student that's also involved. So that graduate student then gets the Qualtrics data, and it's linked back to a program that they have that's called NextGen. So they have... There is a couple... There's a little bit of manual maneuvering to get it back into the system. They also... That graduate student also kind of... Who oversees some of the data can look back at participants that are enrolled, and we can also pull out clinic-based blood pressure data as well. So we ask all of the grantees to document where that blood pressure was taken. Is it a self-report? Is it in the clinic? You know, did they get it when they went to the grocery store, whatever? Just so we have an understanding of the context, because we know the context kind of changes the reading. I'll say at Hopkins, the system is... This is a challenging issue, I think, across the board. So there's not really a great organized SMBP program there, but we do... We see that there are many places where data is recorded. You have physicians just typing into the note, you know, a manual blood pressure repeat that's in the text of the note. You have the vitals that are recorded by the staff. And then we have patients using MyChart now, so messaging through the chart, sending loads of information that can be lost in the ether. And so we're able, with our data team, able to look at most of that. But we also have a MyBP tool, so it's an order that you just send to the patients, and we're asking them to put their home blood pressures in that MyBloodPressure tool, and if they type it in there, it auto-populates into Epic under a chart that has patient-populated vitals. So that is a better system. That is not consistent. A lot of providers don't know about that. So there needs to be a lot of education about coaching patients and providers to use that order and to enter the data there. So this is definitely a challenge across the board. Great question, and just to summarize in case people didn't hear, the question was asked, particularly given the workload that PCPs have, how do you handle the workload or potential workload of patients who have hypertensive urgency with these types of projects? Who wants to answer? Okay, great. So what we did at Cook County Health, because we built into our EHR what we call a hypertension action plan. So this is something that physician, I was part of that group where we kind of did something like with the asthma, like to tell patient what to do. So if their blood pressure is like, let's say it's over, let's say 200 over 120, definitely we ask them to come to the urgent care. We don't ask them to wait for the next appointment, but we tell them that let's say if the blood pressure is 160 over, because that's why the SMBP techniques is so important. It's not just giving them the monitor, let them check the blood pressure. No, we have to use validated BP cuffs, right? There's a list online where you can find out which one is validated. And then we need to really teach them the proper techniques, because if it's not done correctly, because even in the office, that's why at CCH, we confirm BP when it's high. Because usually when you let the patient rest for three to five minutes, you make sure they empty their bladder, you check the BP. That's how it goes down, most of the case. So for, yeah, we are overworked, we don't have a lot of time, but what we do usually when it's high, we try to get them in for, to see, we have what we call care management visit that are done by our nurse, our RN, so that they can come into the office for a repeat BP check. We make appointment for those, but they are free to come in any day that we open to have their blood pressure checked. And then we can confirm the BP if it's high, and then talk to the provider. That's how we handle it. And welcome, and glad you made it OK. Yeah, I have the usual flight situation. At Henry Ford, when we, I had mentioned that we built the RN program, the RN blood pressure titration program, about 10 years ago. And that was the very first thing we did, is built in parameters for based on what the blood pressure reading was, and if it got to a certain point that the provider had to be contacted and take a look at the patient. But we did build that in through the whole process, so that if the patient really needed to be seen in the ED, or if the patient was at home, needed to be seen by urgent care, that we had that built into our parameters. And then when the embedded pharmacy program was created some years later, after the nurse program, a similar program, or similar requirements were built into their program as well for consistency purposes. So that it was being addressed, that not every patient had to be seen by the provider. But we did have some guardrails up for when patient's blood pressure was elevated. But as was mentioned, we did also initiate the AOBPs, the automated office blood pressure devices, a couple of years back. And with the patient resting, with the three readings, and then the averaging, we did find out that a lot of patients' blood pressures really did calm down after they had a chance to relax and rest for a little bit. So does that answer the question? OK. OK, so we've got three minutes left. I'd love to have another question, if possible. Great. Okay, so just for a brief summary, there was a question about delegated authority and how grantees are planning to deal with that potentially in the future and whether CDC and ACPM could maybe put together a tool outlining what's going on or outlining the status by state. What we did at Cook County Health is that we have a medication suggestion list. But at Cook County Health, a provider are the one who will adjust the medication if needed. So even during care management when the blood pressure is high, the nurse need to let the provider know. So that medication suggestion list is available for all provider to just click on it. We put it on the EHR so that you can have access to see what is what you do next. Then we do know that guideline, direct the medical therapy access to add another class of medication instead of, let's say if the patient is taking amlodipine 5 instead of going to 10, maybe it's just better to add that diuretic out there or to add that Lorsatan. So intensification and what we do at Senstack and at all the other clinics from Cook County, is that during the staff meeting, we talk about hypertension, we see where we are, and then we ask each provider to be more optimized treatment. Not just say, okay, come back and see me when your blood pressure is like that. We try to be more proactive because myself, my experience, I had a patient in the office that was having a stroke. My only thing was that he was coming for the first time to the clinic. He was late for the appointment. The clerk asked me, do you want to see this patient? He's late. I'm like, no, I'm going to see him. He's here. Then in the room, I'm like, welcome to Senstack. Then he said that he was late because he got lost coming to the clinic. I'm like, do you live in the area? He's like, yeah, I live in Chicago. I was born here, but I got lost coming to the office. His pressure was very high. Then I asked the medication. He was a little confused. Then he said something about his mom. Then I said, do you have the phone number? I called the mom and she was like, oh, yeah, my son was just in the hospital. He just had a stroke and he was having another one in the office. My only clue was that he got lost coming to the office. Blood pressure is killing people. It's dangerous. That's why we have to be more proactive. Thank you. Can we have Dr. Biola say something? Okay. So it's three o'clock. But sure, Dr. Biola, come up and say something. The person who did your presentation, though, did a stellar job. I've heard that she's amazing. I think the thing that we did that was innovative was use students for patient outreach, and it really extended our reach incredibly. I counted up the humans that were involved in this project, and I got to 1,504 last night before I lost track. Most of it was like 1,200 patients, but it was another 300 people that it took to get students involved and keep them involved and get their HIPAA stuff signed. But so it was a giant effort. But I think touching that many people, I feel like is what's necessary with a problem this big and this pervasive. So it was exciting. If you have any questions about using students for outreach, let me know. I'm here. It was undergraduates, and these were largely undergraduates who want to be medical students, which is why they were so enthusiastic to help us out, because this looked really good on their resumes. I mean, they got actual one-on-one patient contact. We had these huge lists of people with crazy high blood pressures that we divvied up by student and said, you, you get 12 people, go, here are your scripts. Try to reach as many of them as you can, get them a blood pressure cuff, get a reading, here's the stuff to say, and we did a little, you know, we did a little education with the students and had them sort of pass a test before they went out there, but they really had the AHA kindergarten level, here's what hypertension is, here's what it does to your heart and your kidneys, all that, before they went out and had to, you know, see one, do one, teach one kind of thing. But I, their enthusiasm, I will say, is not matched by my staff, nor me, some days. I'm so sorry for the multiple delays. I think I have to let you go, but I'd like to say thank you on behalf of all of our grantees and our speakers, as well as the ACPM staff who support us in this project. Thank you so much for your enthusiasm and your warmth. Have a happy conference.

ACPM Hypertension Demonstration Projects

African-American men

screening

testing

enrollment

self-measured blood pressure monitoring programs

social determinants of health

Cook County Health System

Henry Ford Health System

Lincoln Community Health Center

University of Alabama

blood pressure monitors

classes