Keywords: uncontrolled hypertension; blood pressure self-management and education program; barriers to care; federally qualified health centers; patient-centered medical home; motivational interviewing; social determinants of health; primary care; Watts Health Center
Hypertension is a disease which can lead to stroke or heart disease, both being leading causes of death in the United States. The Los Angeles Department of Public Health provides data for over 60 health indicators for L.A. County and each of the county’s eight Service Planning Areas (or SPAs). SPA 6 in South L.A., in which Watts neighborhood is located, has the third highest percentage of adults diagnosed with hypertension when compared to the other seven SPAs in L.A. County based on the most recent health report in 2017. Although Watts residents have access to care through Watts Health Center (WHC), a federally qualified health center and patient-centered medical home, that provides a full range of services including clinical, preventive, behavioral, restorative, and specialty services, there are still a large number of patients with uncontrolled hypertension (blood pressure, BP >140/90) seen at WHC.
The purpose of our study is to help patients with uncontrolled hypertension take an active role in their healthcare and enable them to manage their health on a day-to-day basis by enrolling them in a 3- and 2-week blood pressure self-management and education program (BPSMEP). As part of the program, we will identify some of the barriers Watts Health Center faces when treating patients with hypertension along with the barriers patients with uncontrolled hypertension experience in managing their blood pressure to aid in the delivery of patient-centered care at WHC.
WHC’s electronic health record system, eClinicalWorks, was queried for patients with a diagnosis of hypertension with diabetes and hypertension only with blood pressure >140/90 from June 1st, 2017 to May 31st, 2018. Patient information such as name, phone number, email and language preference was documented for outreach purposes. Patients were recruited through text, email, and via home and cellular phone to participate in the study. Patients were also offered an incentive for participating in the program. One-on-one hypertension education sessions were conducted with patients who agreed to participate in the study. Patients were loaned a digital home blood pressure monitor and given instructions on how to use the blood pressure monitoring device accurately. They were instructed on how to take their blood pressure following American Heart Association guidelines and to log their blood pressure readings on the paper log provided. During the hypertension education sessions, WHC and patient’s barriers to care were explored and patients created healthy lifestyle goals by using motivational interviewing. Patients were referred to a registered dietitian and received follow-up calls once a week to track their progress and encourage program completion. At the completion of the 3- and 2-week programs, patients returned blood pressure monitoring device and completed blood pressure logs. Patients also completed a program exit survey.
There was a total of 17 patient participants, ranging from ages 37 to 83. Of the participants, 8 identified as Black, non-Hispanic/Latino origin with an English language preference and 9 identified as White, Hispanic/Latino origin with a Spanish language preference. Group A consisted of 9 participants, 6 females and 3 males, with hypertension (HTN) only. Group B consisted of 8 participants, 4 females and 4 males, with hypertension and diabetes mellitus (DM). Patients reported the following top 5 barriers to controlling their blood pressure: stress from home environment, diet, lack of exercise, addiction to smoking, and not taking medications as prescribed. Upon exploring each of the patient’s barriers, different social determinants of health were identified. In addition, the top 5 lifestyle modifications patients elected to implement during the intervention were exercise, diet, stress management, avoiding or limiting smoking, and taking hypertension medication as prescribed. Among the WHC barriers to care: limited resources, clinic hours, lack of continuity of care, and patient distrust in the healthcare system were identified. Upon analyzing the blood pressure values reported by the patients, Group B had the greatest decline in systolic and diastolic blood pressure for both morning and night times when compared to Group A. Overall, 71% of the patients showed a decrease in their blood pressure from baseline to last recorded value.
The social determinants of health underlay the self-reported patients’ barriers to care. Additionally, the use of motivational interviewing to promote healthy lifestyle modifications can improve patients’ self-management behaviors and health outcomes. Through the BPSMEP, a patient-centered intervention was created based on patients’ barriers to care, which aided patients in changing their lifestyle behaviors and reducing their blood pressure values.