AMGA and Pfizer Inc. present the Models of Excellence Collaborative on Patient Adherence and Health Literacy

University of Vermont, Fletcher Allen Health Care, Burlington, VT
Getting to Goal: Patient Directed Blood Pressure Control

EXECUTIVE SUMMARY: The overall goal is to develop a strategy that will allow clinics or practices to increase the proportion of their patients who have BP at goal by increasing patient capacity to adhere to and direct their care. The specific objectives of this demonstration project are to 1) increase the percent of people, at high risk for adverse cardiovascular or renal outcomes, who have BP at goal (less than 130/80 mmHg for diabetes and renal disease and less than 140/90 mmHg for others); 2) increase patient awareness of his or her BP goal and capacity to achieve it; and 3) increase physician awareness of patient perceived barriers to achieving their BP goal. We choose high risk patients in a renal outpatient practice not at goal as the target of this demonstration project

The program focuses on increasing patient capacity to monitor, analyze and direct BP treatment by providing each patient with 1) education about the importance of BP control the ability to measure it, 2) an individual BP goal, and 3) an effective mechanism for changing treatment to achieve the goal. By using a combination of strategies shown to be successful in previous studies to improve BP control in groups, together with patient empowerment, we anticipate that the strategies involved in this program will increase BP control at minimal cost to the practice group. Should this strategy be shown to be feasible in our complex, high risk patients, we propose to test it in other settings including, cardiac and endocrinology clinics and primary care internal medicine practices.

PROJECT PLAN: From our renal clinic population, patients with hypertension and one or more other adverse cardiovascular risk factors whose BP readings not at goal on their most recent visit will be identified. Chart review will identify those who have 2 or more BP readings above goal in the past 6 months. Each person will be contacted and asked if they would like to participate in a program to improve BP control. At the next clinic visit, as long BP is not at goal, each participant will follow the program below. Each person will be seen in clinic at least every 2 months and have BP measured by one of the 3 clinic nurses with a DINAMAP. At baseline 6 and 12 months each participant will complete a questionnaire evaluating patient knowledge and behaviors about BP (see Appendix A). Throughout the study each patient will have his or her antihypertensive care regulated by his or her nephrologist with consultation with other health care providers if necessary. After 6 months participants will be given the option to continue the monitoring program or revert to usual care. In both groups outcomes will be assessed at 12 months.

Patient directed care plan
Each person will be given a BP goal, given a 1 hour education session about the importance of BP control, either in a group or as an individual, and provided with information about treatment options including potentially beneficial lifestyle changes (see Appendix B). In addition, each will be provided with a sphygmomanometer and trained to use it. Each person will be asked to:

1. Measure and record BP and pulse (after rising in the morning and before taking any medications and after supper in evening) every day during “active” periods and one day a week during maintenance periods. Active periods include the 2 weeks at the beginning of the study, two weeks after any change in medications from the clinic or from another physician and two weeks at any other time that patients or physicians are concerned about BP not being at goal. Maintenance periods include all other times during the study.
2. Phone, FAX, Email or mail readings to clinic nurse after any two week active period and every two months for maintenance periods.
3. Evaluate if BP is at “goal” every two weeks during active periods or every two months during maintenance periods. This will be done by viewing the BP chart and determining if there is more than one BP reading above the goal for every two BP readings at or below the goal for systolic blood pressure for the period being assessed (see Appendix C).
4. Contact clinic nurse by phone FAX or email if, by this definition, BP is not at goal, to get instructions about how to improve BP control. The clinic nurse will show the patient information and clinic record to the patient’s physician who will make changes in treatment. The nurse will inform the patient of the changes within 24 hours and instruct the patient to takes BP twice a day for the next 2 weeks and again contact the clinic if BP is not at goal. This pattern will be repeated until BP is at goal then the maintenance phase will begin. Patients will be instructed to keep all their BP charts so that they can be checked at the next office visit for correct interpretation. Also patients may contact the clinic nurse whenever they feel their BP is not at goal at times other than those described above.
5. Record BP, pulse, date for readings taken in any physician’s office. Monitor BP for 2 weeks if changes are made and contact that the renal clinic nurse if BP is not at goal.

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