Identifying Successful Strategies for Implementing Team-Based Home Blood Pressure Monitoring in Primary Care

Hypertension is the single most important, medically modifiable risk factor for the prevention of cardiovascular disease in the United States. Control of hypertension is critical to improving the length and quality of life in the United States and for addressing racial disparities in cardiovascular disease. Yet, national progress in controlling hypertension has stalled. The current model for hypertension care in the United States, which relies nearly exclusively on clinician-driven office visits, has proven inadequate. There is an urgent need for team- based, patient-centered models of care. Team-based home blood pressure monitoring (TB-HBPM) represents an evidence-based practice that is widely underused in primary care. Strategies are needed to promote its adoption in primary care. Based on published barriers to adoption of TB-HBPM, successful strategies must engage patients and clinicians in the implementation process, and provide patients and their care teams with the knowledge, skills, resources, and data needed to implement and sustain TB-HBPM. Notably, strategies must address financial sustainability. The primary goal of this proposal is to identify and rigorously evaluate translatable strategies for implementing and sustaining TB-HBPM within primary care. To accomplish this aim, we will recruit seven practices from a single site where hypertension control is suboptimal. These practices serve predominately low-income and minority patients. In phase1 (R61), we will convene a steering committee that includes patients, practice staff, and clinicians to guide planning, implementation, sustainability, and evaluation (Aim 1). During phase 1, we will assess the specific barriers and facilitators to implementing TB-HPBM within these practices. Based on these practice-specific barriers, we will operationalize strategies using the Practical, Robust, Implementation, and Sustainability Model (PRISM). In phase 2 (R33), we will deploy these implementation strategies using a hybrid type-2, stepped wedge cluster randomized trial (Aim 2). Implementation strategies will include patient and team training, actionable data provided to the teams, and adoption of new billing codes. We will assess the impact of implementation strategies using the Reach, Effectiveness, Adoption, Maintenance (RE-AIM) framework (Aim 3). Our primary outcomes will be HTN control and patient use of HBPM. Secondary outcomes will include the proportion of patients with uncontrolled BP who are seen within 60 days, establishment of team charters by teams (adoption), and financial sustainability based on a cost analyses (maintenance). We will use realist evaluation to test theoretical assumptions underlying the implementation strategies (Aim 4). This mixed-methods approach will allow us to develop transferable lessons for other settings. Our findings will advance the science on implementation of successful HTN management models and provide a roadmap towards broader implementation of TB-HBPM in primary care.