Blood pressure management for complex care

Care management & redesign Data analysis & integration SDOH & health equity

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High blood pressure is one of the most prevalent chronic conditions in the US, with nearly half of adults carrying a diagnosis of hypertension. While the state of New Jersey’s hypertension rate was 30.2% in 2017,1 a 2021 report that indexed American cities ranked Camden 20th in the country with a rate of 39.9%.2 Our data shows that up to two thirds of participants in our Camden Core Model care management program have a cardiovascular diagnosis.

Project goals

  1. Pilot a short-term, home-based intervention with patients living with stage 2 or higher hypertension in combination with other complex health and social needs.
  2. Identify relevant implications for Medicaid operations, including ease of access to blood pressure cuffs, medication, and prior authorizations, and generate hypotheses about the use of the ED by patients despite active connections to primary and/or specialty care.
  3. Learn more about how a community-based care management program can serve as an effective extension of primary care for individuals with complex health and social needs.


Few studies exist that focus on blood pressure management in patients who face the level of medical and social complexity of our Camden Core Model participants. Successful interventions among less complex populations have included components such as:3,4,5

  • access to home blood pressure monitors;
  • proactive medication management;
  • patient education;
  • lifestyle changes in areas such as physical activity, diet, & stress management; and
  • ongoing blood pressure monitoring.

While the Camden Core Model has always served a high proportion of patients with cardiovascular diagnoses, we have never had a targeted approach to address these specific conditions. Rather, we have worked on empowering patients to take control of their health in a broader sense — supporting them in navigating fragmented healthcare systems and accessing critical social support, such as housing, public benefits, and legal services. Due to the complexity of our patient population, even our patients with strong connections to primary and specialty care end up in the ER or hospital due to challenges with the ongoing management of their conditions.

This led us to think about piloting new ways for our patients to engage with their blood pressure management in the community, using an eight-visit model to build capacity and skills that, we hoped, would set patients up for 1) better home management of their hypertension, and 2) more productive relationships with their providers to facilitate sustainable strategies for ongoing maintenance.

In addition, the Camden Coalition is interested in determining why patients with active primary and specialty care connections continue to use the ED. Ideally, learning from this pilot will translate to promising practices for primary and specialty care teams who have access to other community-based programming, as well as implications for other chronic conditions such as diabetes, kidney disease, cardiovascular disease, COPD, and others.

Project design

The project leverages the Camden Core Model to address hypertension through an eight-visit workflow, based on two hypotheses:

  1. Using our COACH participant engagement framework can support better BP control in patients with complex needs by building self-efficacy in home BP monitoring; identifying relevant and achievable lifestyle changes; building relationships and shared care plans with PCPs and specialists; and building habits and skills that promote better access to necessary services.
  2. Enrolling patients, observing home routines, conducting medication reconciliation, and tracking blood pressures for eight weeks will position community-based care teams to provide a meaningful summary and care plan that can be shared with primary care providers to sustain ongoing successful BP management.

The pilot is carried out by a nurse/community health worker (CHW) dyad as follows:

  • Patient identification and enrollment: Identify patients during a hospital/ED admission or via partner referrals; conduct chart review to identify patients with uncontrolled hypertension; engage patient bedside to discuss program and enroll.
  • Visit 1 — Nurse-led home visit #1 (Education and baseline): Provide BP education based on recommendations from the American Heart Association, a BP monitor and education on how to use it, and a BP log for the patient to keep track of their readings; conduct a thorough home-based medication reconciliation.
  • Visits 2-4 — COACH for BP management: CHW checks in with each participant to document a BP reading in TrackVia, our patient care database; support connection to a PCP if needed for medication adjustments; use COACH to support lifestyle changes related to medication adherence, physical activity, diet/access to healthy foods, and other factors based on patient needs; and the Patient-Centered Outcome (PCO) measures6 and Voils medication adherence tool is completed during visit 2 and visit 4.
  • Visit 5 — Nurse-led home visit #2 (Nurse check-in): Evaluate medication adherence via the Voils DOSE-Nonadherence tool – a tool that assesses medication non-adherence and the reasons for missed doses; check BP and log in TrackVia; check in on lifestyle changes.
  • Visits 6-7 — COACH for BP management: CHW continues to check in with each participant, completing the activities listed above.
  • Visit 8 — Close out (Conducted by a CHW): Complete final BP check; discuss the plan for ongoing monitoring moving forward; and warm handoff to PCP for continued monitoring. Warm handoff includes a shared care plan with a current medications list and recommendations for practice engagement with the participant.

Measuring success

To measure success of this pilot, we will look at several key process measures, including:

  • Patient engagement metrics:
    • Rate at which participants self-monitor their BP and use their BP log; and
    • % of participants who understand their medications and report adherence (via Voils)
  • Care team engagement metrics:
    • Rate at which team is able to retrieve and document a weekly BP reading;
    • % of participants who receive a shared care plan/warm hand-off to a PCP at the end of the intervention;
    • Time and effort logged by nurses and CHWs over the intervention; and
    • Qualitative notes on how COACH is being used in the context of the pilot
  • Clinical metric:
    • % of participants who achieve meaningful BP improvement;
    • % of participants who maintain BP control after the intervention; and
    • % of participants who experience adverse outcomes (e.g., hospitalization due to hypotension, etc.)
  • Sustainability metrics:
    • % of patients who remain well-connected with primary care or specialists to maintain BP control;
    • Interview patients about which aspects of the intervention continued 6-12 months beyond the intervention; and
    • Interview primary care offices about which aspects of the intervention continued 6-12 months beyond the intervention
  • Teaming metrics:
    • Evaluating the process by which community-based care teams communicate with primary care to build a stronger foundation for ongoing management based on care team’s observations of patients’ normal routines

Progress to date

As of February 2024, the pilot has enrolled 44 participants and 19 have graduated. 52% of recorded blood pressure measurements have been completed by participants. Eight out of nine graduates who responded to a follow-up survey said that they feel “very confident” using a home blood pressure monitor, and seven out of nine reported feeling “very confident” scheduling and attending doctor’s appointments, as well as refilling prescriptions when needed.

Early observations from our team include:

Stronger than expected patient engagement and motivation

Given the complex health and social needs that eligible patients are experiencing, including homelessness, we were skeptical that this pilot would see a high level of engagement. We were surprised to find both a high rate of eligible individuals accepting support, as well as high levels of engagement in routine blood pressure monitoring among many participants. Though we ask participants to log their blood pressure weekly, a number of participants have logged measurements daily and have continued to log measurements even after graduating from the program.

We think that some of this success is due to care team members explicitly connecting blood pressure management to participants’ own stated goals by first eliciting their goals and then asking how the management of their health fits into that. Because many participant goals are complex and long-term, like finding housing, addressing hypertension represents an achievable, concrete goal that can increase participants’ self-efficacy as they work with their care team toward their stated goals. The consistency of the care team’s contact with the participant, and the emphasis on relationship- and trust-building in the context of the participant’s own goals, seems to enhance motivation for participants to work on blood pressure control.

Difficulty getting insurance to pay for home blood pressure monitors

Though home blood pressure monitors are covered by insurance, we have found that obtaining them is a difficult process. This is particularly true for bariatric or other alternative-sized cuffs, which are both more expensive and extremely difficult to find — representing a clear equity issue. Despite our care team members’ extensive experience connecting participants to needed durable medical equipment (DME),7 even they have found the process of obtaining home blood pressure monitors to be uniquely challenging.

We are currently reaching out directly to insurance companies to investigate why this process is so difficult so that we can develop system-level solutions.

Individualized, hands-on support makes a difference

Most patients aren’t trained in how to use a home blood pressure monitor, and we have found that the process can require substantial troubleshooting at the beginning. Extra, hands-on support from care team members helped participants become more confident and willing to use their home monitors.

In addition, most existing patient education around controlling hypertension is one-size-fits-all. Our care team has found success approaching lifestyle change in a more individualized way, based on the participant’s current context. For example, if a participant is living in a shelter with limited control over their nutrition, care team members might suggest using only half of the seasoning packet for their instant noodles, rather than an unrealistic suggestion like cooking more meals from scratch.

Next steps

We plan to achieve our target enrollment of 50 participants by the end of April 2024, and to release a more complete set of findings after enrollment and data analysis are complete.

For more information, please contact:

Michelle Adyniec
Senior Clinical Manager, Care Management Initiatives
[email protected]