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BMC Health Serv Res
BMC Health Serv Res
BMC Health Services Research
1472-6963
BioMed Central London

11485
10.1186/s12913-024-11485-z
Research
implementation of healthy heart ambassador to improve blood pressure control at community health centers in Texas
Heredia Natalia I. natalia.i.heredia@uth.tmc.edu

12
Garza Ella R. 2
Velasco-Huerta Fernanda 2
Swoboda Tracy L. 3
Fwelo Pierre 2
Mathews Patenne D. 2
Fernandez Maria E. 124
1 https://ror.org/03gds6c39 grid.267308.8 0000 0000 9206 2401 Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, 7000 Fannin, Suite 2558, Houston, TX 77030 USA
2 https://ror.org/03gds6c39 grid.267308.8 0000 0000 9206 2401 Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX USA
3 https://ror.org/03gds6c39 grid.267308.8 0000 0000 9206 2401 Center for Quality Health IT Improvement (CQHII), McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX USA
4 https://ror.org/03gds6c39 grid.267308.8 0000 0000 9206 2401 Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, TX USA
20 9 2024
20 9 2024
2024
24 110516 2 2024
23 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Hypertension is one of the most prevalent chronic diseases in the United States and can increase a person’s risk of stroke and other cardiovascular complications. Yet only 1 in 4 people with high blood pressure in the United States have their blood pressure managed. To improve hypertension control, we supported 9 health centers in Texas with the implementation of the Healthy Heart Ambassador Blood Pressure Self-Monitoring (HHA) Program.

Methods

We provided health center training using the HHA Program Facilitation Training Guide, recorded barriers to implementing the HHA program, and employed strategies to overcome those barriers.

Results

There were 68 staff members from the health centers trained to deliver the HHA program. Three health centers successfully implemented all three major components of HHA, three were able to implement two components, two adopted two components, and one withdrew due to insufficient capacity. Capability, technology infrastructure, and motivation were among the barriers most referenced.

Conclusion

Clinic non-physician team members delivering the HHA program will need training and ongoing technical assistance to overcome implementation barriers.

Keywords

Telehealth
Blood pressure
Remote patient monitoring
Community health centers
Self-management
http://dx.doi.org/10.13039/100020365 Centers for Disease Control and Prevention Foundation HHS000353700001 issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcBackground

Hypertension or high blood pressure is one of the most prevalent preventable chronic conditions in the United States (U.S.), with nearly 48.1% of adults, or 119.9 million individuals, affected [1]. In 2021, hypertension contributed to 691,095 deaths [1]. Moreover, hypertension exerts excessive pressure on the arteries, leading to their gradual deterioration and increasing the likelihood of serious health complications, including stroke, heart attacks, atherosclerosis, vision problems, cognitive problems, aneurysms, and metabolic syndrome [2–4]. It is estimated that high blood pressure-related healthcare expenditures cost the U.S. 131 billion dollars annually on average [5]. However, only 1 in 4 adults diagnosed with high blood pressure have their blood pressure under control in the U.S [1].

Hypertension can be controlled through lifestyle modifications, such as monitoring one’s blood pressure, physical activity, a nutritious and balanced diet, adequate sleep, using coping strategies to manage stress, smoking cessation, and using anti-hypertensive medication [6–8]. Self-measured blood pressure (SMBP) monitoring utilizing a validated automatic sphygmomanometer, also known as a blood pressure measurement device, and a healthy diet are two of the most effective and affordable strategies to manage blood pressure and reduce the risk of subsequent cardiovascular disease [8–11]. SMBP performed at home is a better depiction of a patient’s blood pressure compared to readings done in medical facilities that may show temporary, isolated elevation due to an alerting response (i.e., white coat hypertension). Thus, done at home, SMBP may help providers more accurately manage patients’ hypertension, including decision-making about treatment [10]. The American Heart Association (AHA) and American College of Cardiology recommend utilizing an oscillometric device that has been validated according to the protocols of the American National Standard Institute/Association for the Advancement of Medical Instrumentation/International Standards Organization, the British Hypertension Society, or the European Society of Hypertension International Protocol [12]. Regular SMBP monitoring can empower patients to take ownership of their health and use timely information to make real-time behavior changes, such as reducing their salt intake that day [11]. Similarly, SMBP monitoring may improve adherence to medication regimens by making individuals aware of their most current health status [13]. Meta-analyses on randomized controlled trials analyzing the effect of SMBP have found that systolic and diastolic blood pressures gathered in clinic settings were statistically lower in patients who practiced SMBP at home compared to usual care [14–16]. Those who practiced SMBP at home were more likely to meet blood pressure targets provided by their care team [14]. Additionally, reductions in blood pressure were greater with the use of telemedicine [16]. Aspects of telemedicine utilized in past trials included phone calls made by patients to a telephone-linked computer system to report their readings, automatic devices that connect to their phones to synchronize results, and text message reminders [17–19].

Although SMBP and maintaining a healthy diet are effective strategies for controlling high blood pressure, patients may need help with the uptake and maintenance of these behaviors [20–22]. Due to the shortage and heavy workload of primary care providers in the US, physicians have limited time for assisting patients to adopt and maintain these behaviors [23]. Non-physician Team members (NPTMs), including dietitians, healthcare professionals, nurses, nurse practitioners, physician assistants, and pharmacists, can, if trained properly, play a pivotal role in helping patients improve hypertension control. NPTMS can help patients learn how to use blood pressure measurement devices properly, educate them about hypertension, assist in medication management, provide lifestyle counseling and behavior change support, assist patients with telehealth and remote SMBP monitoring, and provide continuity of care [24–27]. Previous randomized controlled trials on the effectiveness of SMBP have employed nurses, health educators, pharmacists, clerical and quality consultants, and health program specialists to implement interventions [19]. Healthcare systems that have adopted team-based care models, enabling NPTMs to implement standardized treatment algorithms and follow-up with patients, have successfully enhanced blood pressure control among their patient population [24–27].

With the goal of improved hypertension control through the adoption and maintenance of management methods including healthy eating and SMBP, we developed strategies to transform standard, manual blood pressure processes into convenient and consistent workflows entirely supported by technology and team-based care. We worked with community health centers in Texas to explore and test innovative ways to engage NPTMs in clinical settings to increase the hypertension control rate by supporting patients in self-management and providing brief nutrition counseling to patients. To achieve this, we facilitated the implementation and sustainment of the Healthy Heart Ambassador Blood Pressure Self-Monitoring (HHA) Program within the health centers.

The purpose of the present paper is to describe the process of training NPTMs from several community health centers on the HHA program. We also describe barriers to implementing the HHA program, strategies to overcome those barriers, implementation successes, and suggestions for future HHA implementation efforts.

Methods

Healthy heart ambassador

The HHA is a program composed of evidence-based strategies developed by the Centers for Disease Control and Prevention (CDC) and the YMCA with three focus domains: (1) blood pressure management, (2) identification and control of triggers that impact blood pressure, and (3) adoption of healthier eating habits with clinical support [28]. The program has been implemented by health centers and state health departments across the United States, with varying reports of fidelity and implementation across sites [29–32]. Health centers have utilized a similar NPTM implementation approach to make the program accessible to their patients [29]. Eligible patients with uncontrolled hypertension who join the HHA program receive guidance and encouragement for a 4-month period, including personalized consultations, educational nutrition seminars, and blood-pressure measurement support. Methods of information and support delivery are embedded into the HHA program, such as modeling the proper steps for SMBP monitoring and active learning opportunities (e.g., tailoring methods of communications and setting and evaluating goals with participants). Furthermore, the nutrition education component emphasizes the DASH (Dietary Approaches to Stop Hypertension) diet, along with the importance of consuming a reduced-sodium diet, which are lifestyle modifications recommended by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) [33] and are shown to reduce systolic blood pressure in clinical trials [34–36].

The HHA program recommends that the facilitators (implementers) meet with the patients weekly for office hours (16 sessions of a minimum of 10 min each) and deliver monthly nutrition sessions (4 sessions of a minimum of 50 min each) in person or remotely. The initial office hour session can serve as the HHA patient onboarding session. During the onboarding sessions, patients are officially registered (i.e., fill out the program registration and blood pressure measurement device loaner form), receive an automatic sphygomomanometer, (blood pressure measurement device), and are taught how to measure their blood pressure properly. They also receive assistance with set up (connecting the blood pressure measurement device to their smartphone) and downloading blood pressure data as needed.

The study team attended a CDC-YMCA HHA training and received the curriculum, including the Program Facilitation Training Guide, four nutrition seminars, and the HHA Trainer Guide. The Program Facilitation Training Guide with the corresponding PowerPoint presentations was used by the study team to train community health centers’ staff.

Clinic recruitment

The study team recruited nine community health centers in Texas interested in participating in the HHA program. The program was presented to partner community health centers who were interested in improving their team’s capacity to identify, monitor, and manage patients with uncontrolled hypertension. The goal was to engage NPTMs in hypertension management. These community health centers either had an SMBP monitoring program in place and wanted to enhance their program or were planning to restart or start a new program. Participating health care organizations included two health centers in South Texas, including an urban family practice and a rural federally qualified health center (FQHC). In the Dallas-Fort Worth Metropolitan, there were three FQHCs. There was one urban FQHC in the Houston area and one in East Texas. In the Gulf Coast region, there was one urban FQHC and one rural non-profit health center. This project was approved by the institutional review board at UTHealth Houston (HSC-SPH-21-0180). The need for consent to participate was waived.

Health center training

We used a train-the-trainer implementation strategy [37] to train designated NPTMs to become HHA facilitators (implementers) so that they could educate and train patients with uncontrolled hypertension on how to properly measure their blood pressure at home and make heart-healthy dietary changes. Between 2021 and 2023, we organized and hosted seven HHA training sessions. The purpose of the training was to teach NPTM how to deliver the HHA program for hypertension management with fidelity. Prior to selecting the training dates, our team consulted with the community health centers’ NPTMs on what days were best for their staff to attend onsite and remote training. The community health centers received an email with a flyer that included information about the training opportunity a month before the first scheduled training, along with instructions on registering using their email. The one-day training lasted five hours (9:00 a.m.- 3:00 p.m.) and it was hosted via Webex (online video conferencing platform). However, we provided on-site training to 5 staff members for centers in rural South Texas since their internet connection posed a barrier to remote training. We also provided the health center staff with an annual 1-hour long refresher training on proper blood pressure technique via conference call.

Our team used the CDC-YMCA HHA curriculum to train community health centers’ staff. The training was composed of large group lectures, role-play practice in small group break-out sessions, and assessments. During the break-out sessions, participants had the opportunity to practice the proper techniques for measuring blood pressure. Community health centers enrolled staff members to train on multiple occasions to (a) achieve staff competency with assigned role/job duties, (b) train new staff due to staff turnover, and (c) train members of the administrative or leadership teams.

Materials for implementation

Before the training, those who registered were provided with the training agenda and the CDC’s HHA Pre-Read via email. All participants who completed the training received the HHA program implementation curriculum including a Program Facilitation Training Guide, and four nutrition seminars, provided by the CDC. Additionally, we provided each participating community health center with an implementation packet developed to facilitate the implementation of the HHA program, described below.

We used Implementation Mapping to develop the implementation packet shared with each participating community health center [38]. This implementation packet contained clinic and patient-facing items. All patient items were developed in English and Spanish. All patient-level items were checked to ensure they were appropriate to meet the various literacy levels of the patient population served by the community health centers. The implementation supporting materials included:

Hypertension and SMBP guidelines/policy

These documents delineated best practices for identifying patients with hypertension and referring patients with uncontrolled hypertension to the HHA program. Patients were considered ineligible if they had experienced a recent cardiac event within the previous 12 months, had atrial fibrillation or other arrythmias, and if they were at risk for lymphedema.

HHA clinic protocol

The protocol described the health centers, and program facilitators (implementers) responsibilities, patient enrollment workflow, and patient responsibilities and eligibility. We aligned this protocol with the HHA program workflow (Program Facilitator Guide, page 7). This protocol provided health center staff with a summarized roadmap of responsibilities, how to implement the program, and use the resources.

Registration and loaner forms

These included a patient registration form, blood pressure measurement device loaner form, and Excel sheets to track and average the patients’ blood pressure. These forms were developed to be used as part of the onboarding process to register newly enrolled HHA patients. The blood pressure tracker was developed to help clinics using paper logs to better track patients and facilitate averaging the blood pressure readings over the 16-week HHA program (4 months).

Referral pads

Referral pads were developed to facilitate referrals to the HHA program and provide patients with contact information for the health centers’ HHA facilitator. The pads were customized for each health center.

Patient protocol

This document provided patients with an overview of what to expect from the program including a delineation of their responsibilities and expectations.

HHA facilitator presentation

This presentation provided visual support for the pre-, during, and post- HHA visit process. It included videos (e.g., proper steps to measure blood pressure accurately), infographics (e.g., blood pressure stages) and best practices for SMBP monitoring. Items presented in this presentation included resources from the AHA, American Medical Association (AMA), and the CDC.

Billing resources

The billing resources included Centers for Medicare & Medicaid Services (CMS) Current Procedural Terminology (CPT) codes provided by the AMA, CMS, Texas Health and Human Services, and the National Association of Community Health Centers to help health centers with payment reimbursement for the services provided for SMBP monitoring and chronic care management.

Training assessment

Participants completed a pre- and post-assessment to evaluate their knowledge and training satisfaction and give the trainers feedback. The trainer also performed a competency evaluation, the Program Facilitator Training Evaluation, during which the participant was rated on their knowledge, communication skills, and use of techniques for properly measuring patient blood pressure. Participants had to score 5 out of 7 or higher to receive a passing score. Participants also completed a pre- and post-assessment in which they were evaluated on their knowledge and training satisfaction and were asked to evaluate the HHA trainer. Seven of the pre- and post-assessment questions were related to the Trainer Feedback component, which was added in 2023.

Technical assistance support

Once the health centers were trained and received the supporting materials, we provided monthly technical assistance to support practice facilitation and ensure program implementation.

The health centers had the opportunity to meet monthly with the study staff either in-person or via an online video conferencing platform to discuss the progress of HHA implementation, review, and audit data (referrals, enrollment, compliance, etc.), troubleshoot issues, and provide ongoing support monthly. The study staff took detailed notes regarding adoption, implementation and maintenance of the HHA program, along with potential challenges, strategies and recommendations to overcome barriers. We grouped these barriers based on the constructs from the Consolidated Framework for Implementation Research (CFIR) [39] and present those below.

Results

A total of 68 individuals were trained from the 9 community health centers. Participants were both NPTMs and leadership from these health centers. There were 2 clinic coordinators, 3 nursing supervisors, 26 medical assistants, 1 medical assistant supervisor, 7 patient navigators, 1 community health navigator, 1 community health navigator coordinator, 1 outreach and enrollment coordinator, 1 nurse practitioner, 1 chief nursing officer, 4 care managers, 1 diabetes educator, 1 SMBP coordinator, 1 director of public health, 1 development officer, 1 strategic planner, 1 behavioral health clerk, 2 patient service clerks, 1 operations manager, 2 office managers, 2 community impact directors, 1 physician assistant, 1 pharmacy intern, 1 Doctor of Nursing Practice student, and 4 wellness specialists.

Training assessment

Of those who attended the training, 40 trainer-observed evaluations were completed. Of those, 35 participants were observed communicating the importance of using the same arm and having a consistent time of day for self-measuring, and 35 participants accurately shared the factors that can affect blood pressure readings. Moreover, 39 were observed reviewing tips for proper blood pressure measurement and checked for patient questions, 34 accurately communicated the number of times a day a patient should measure their blood pressure, and 35 demonstrated and communicated proper blood pressure measurement technique. Lastly, 39 of 40 demonstrated appropriate listening skills and all 40 participants demonstrated a safe and judgment-free environment.

We also collected self-reported data from participants post-training. Of the 49 participants, 45 were satisfied with the training as a whole, 46 were satisfied with the accessibility of the course, and 41 indicated that their knowledge of the topic was much improved post-training. When asked how confident they were applying the information from this training at their health center, 46 of 48 (one was missing) responded they were extremely confident. Overall, the participant attendees demonstrated understanding of the HHA training content, including patient eligibility guidelines and the responsibilities of a program implementor (facilitator). The trainees also demonstrated knowledge of what high blood pressure is, what readings or blood pressure ranges constitute different risk levels, and why SMBP is effective in behavioral change.

Implementation of HHA

We quantified adoption, implementation, and maintenance sub-steps (i.e. achieving specific Performance Objectives) completed by each community health center to determine the level of implementation at each stage. Adoption involved adopters, such as HHA educators and clinic leadership, attending the HHA training, agreeing to adopt the program, allocating resources, identifying staff to implement the program, assessing clinic readiness, and creating implementation plans. Implementation involved utilizing program tools, enrolling patients, and conducting office hours. Maintenance of the HHA program implementation was achieved through the continuous sustainment of the program, such as new patient enrollment (starting new cohorts), leadership’s continuous commitment to the program, quality improvement, data monitoring and feedback, and resource allocation. The community health centers adopted, implemented, and/or achieved the maintenance phase of the HHA program at different times between 2021 and 2023. The variability in the implementation stage (adoption, implementation, and maintenance) achieved among health centers was attributed to the timing of their engagement with the program and their capacity throughout the process.

Table 1 Health centers healthy heart ambassador program implementation status (N = 9)

Health Centers Participating in the HHA Program	Level of Implementation	HHA Components Delivered	
Dallas-Forth Worth area urban FQHC	Implementation	Recruitment

Office Hours

Nutrition Seminars

	
Dallas-Forth Worth area urban FQHC	Adoption	Recruitment

Office Hours

	
Houston area urban FQHC	Maintenance	Recruitment

Office Hours

Nutrition Seminars

	
East Texas urban FQHC	Implementation	Recruitment

Office Hours

	
South Texas rural FQHC	Implementation	Recruitment

Office Hours

	
South Texas urban family practice	Implementation	Recruitment

Office Hours

	
Gulf Coast rural non-profit health center	Withdrawn	Withdrawn	
Gulf Coast urban FQHC	Adoption	Recruitment

Office Hours

	

Table 1 shows the components of the HHA program that each community health implemented successfully. For instance, five health centers successfully implemented the program (sent staff to HHA training, recruited and onboarded patients for the HHA program, and implemented all or some of the HHA components). However, since community centers joined the HHA program at different time periods and faced barriers during implementation, only one reached maintenance during this project. Furthermore, three health centers delivered all three major components, with one able to maintain the program, while three health centers only implemented two components (recruitment and office hours). Two clinics adopted two components (recruitment and office hours), and one health center withdrew from the program due to staffing shortages and insufficient capacity.

Implementation barriers to HHA

In Table 2, we present the frequency of some of the implementation barriers reported by the health centers, categorized by CFIR constructs.

Table 2 Health centers reported barriers to the implementation of the healthy heart ambassador program (N = 9)

Barriers to Implementation	Frequency	
Capability-The individuals had interpersonal competence, knowledge, and skills to fulfill the role.	9	
Technology Infrastructure-Technological systems for tele-communication, electronic documentation, and data storage, management, reporting, and analysis support functional performance of the Inner Setting.	8	
Motivation - The individuals were committed to fulfilling the role.	8	
Work Infrastructure-Organization of tasks and responsibilities within and between individuals and teams, and general staffing levels, support functional performance of the Inner Setting.	7	
Engaging Innovation Recipients- Individuals who are directly or indirectly receiving the HHA program.	7	
Funding- Funding availability to implement and deliver the HHA program.	6	
Note: Constructs from the Consolidated Framework for Implementation Research (CFIR)

Capability

All the health centers reported capacity issues. Many health centers experienced challenges with staff shortages and turnover, thus staff were trained periodically at these health centers to ensure staff integration into the new workflow. However, staff turnover also caused absences from training- people that had signed up found themselves unable to attend due to staff shortages at their clinic and needing to provide coverage. Several health centers had to place the HHA program on hold at different times due to the loss of staff who were trained in HHA- and had yet to have new staff trained- or had too many integral members out on leave. Some health centers did not have or lost their Spanish-speaking HHA and thus were only able to reach English-speaking patients or relied on other clinic staff to facilitate translation for the patients. This made the delivery of the nutrition sessions especially difficult.

Some HHAs did not feel competent to deliver the HHA nutrition sessions although they were provided with the presentation slides and lessons. Although the health center staff delivering the HHA program took the HHA training, they had diverse backgrounds and thus their level of comfort delivering the nutrition sessions varied. Their main concern was about being unable to answer the patients’ questions. Lastly, not all health centers had the space to conduct nutrition sessions in-person onsite.

Technological infrastructure

Many health centers- and their patients- had technological infrastructure issues as well. These included patients experiencing issues with the SMBP monitoring equipment, especially the readings not being recorded by the blood pressure measurement device, and patients living in remote areas reporting problems with internet access and connectivity. Some patients also had low technological literacy that was not overcome with instructions, such as not knowing how to connect smartphones to the blood pressure measurement device, how to enable Bluetooth settings on smartphones, or how to reconnect blood pressure measurement devices to the smartphone if they became disconnected due to phone updates. For example, patients using the Welch Allyn blood pressure measurement device’s application experienced issues when conducting smartphone updates [40]. After updates were completed, patients were unable to log back into the application and/or had their connection to the patient portal disabled and thus the clinic staff was not able to see their blood pressure readings. Moreover, to connect the remote blood pressure reading measurement devices, some health centers needed multiple applications to integrate the blood pressure reading into the patient portal, depending on the electronic health record (EHR) the health center had, and the blood pressure measurement devices that they were using. For example, clinics who utilized eClinicalWorks as their EHR needed access to the Healow application, and clinics additionally needed to use the mobile application according to the blood pressure measurement device they utilized, either Welch Allyn or Omron [40–42]. Staff were also responsible for helping their patients create accounts for either the blood pressure measurement device manufacturing company or the health center patient portal. This created extra work for HHA facilitators (implementers) since they had to go to multiple portals to track the patients’ blood pressure or download the data from one portal to the other. One clinic was completely unable to connect the remote patient monitoring (RPM) blood pressure measurement device applications to the EHR.

For clinics who had persistent patient- or clinic-level issues, patients were provided paper logs to track their blood pressure and share them back with the HHA facilitator, though this also created additional work for the HHA implementer, as they needed to manually enter the readings weekly into the EHR.

Motivation

Competing priorities decreased motivation among some HHA implementers. Staffing shortages and time constraints- they were overwhelmed with the over assignment of duties- made them less likely to prioritize HHA. Some health centers’ leadership, administrative staff and/or clinical providers were unmotivated to participate because there was no reimbursement incentive for the services provided (patient office hours and patient nutrition education sessions) as many of the patients served by the health centers were uninsured and the HHA time commitment was costly (staff time allocation).

Work infrastructure

Many of the health centers were overwhelmed due to staffing shortages, changes in leadership, staff retention, lack of support from clinic leadership, and the required changes to make their clinical workflow more efficient. These challenges impeded the ability of the health center to attend HHA trainings and move along program implementation or implementation of all components since new staff needed time to get familiar with ongoing projects. This also resulted in multiple cancellations of HHA implementation meetings (i.e., technical assistance calls).

Funding

The lack of coverage for devices and reimbursement of provider time remains a barrier to the broad use of HHA monitoring for the diagnosis and management of hypertension. Many health centers were unable to use CPT codes initially suggested by the HHA program to bill for SMBP services. Although CPT codes were available, only a small number of private payers and Medicaid plans provide coverage for SMBP. For example, CMS does not reimburse FQHCs separately for RPM services. Medicare’s position is that RPM is a component of care management under the perspective payment system (PPS) qualifying visit and is therefore covered through the associated PPS payment rate. To be eligible for reimbursement for RPM, including SMBP services under CPT code 99473, FQHCs should bill G2025 if delivered via telehealth until the end of the Public Health Emergency. For FQHCs, the CPT care management codes crosswalk to HCPCS G0511. The payment rate for HCPCS G0511 is the average of the national non-facility payment rate for FQHC care management. FQHCs can expect the payment to be slightly higher or lower depending on the Geographical Adjustment Factor or Geographic Practice Cost Index. G0511 may not be billed when a patient is also receiving Chronic Care Management or Complex Chronic Care Management. G0511 can be billed just once per calendar month. In addition, the I-10 coding, which provides the patient’s diagnosis and/or treatment information and is used for billing purposes, did not generate robust revenue to offset the laborious efforts to execute the HHA program.

Funding was also an issue around the actual blood pressure measurement devices. For example, three of the health centers with Health Resources and Services Administration (HRSA) grants had received many validated oscillometric blood pressure measurement devices and so actually had the capacity to enroll a larger number of patients into the program with the proper devices. However, following up with this large volume of patients per HHA recommendations was not feasible since it would require a tremendous amount of time. Lastly, some clinics required extra-large blood pressure measurement cuffs to accommodate patients of all sizes; however the health centers had previously purchased or received regular-sized cuffs only and did not find available funds to purchase larger ones.

Engaging patients

Health centers reported that some participants were unmotivated due to difficulties using the blood pressure measurement devices, problems with internet access, technology issues, the considerable time commitment required by the program, and a lack of motivation to make the lifestyle change needed to control blood their pressure.

Strategies used to address implementation barriers

Despite barriers to implementation, several health centers were successful in implementing HHA. One health center conducted patient follow-ups and nutrition sessions. The healthcare providers followed-up every three months with the patients while the dietician provided patient education one-on-one. At-home blood pressure readings helped providers make informed decisions and improve care during the patient’s follow-up visits. Another health center partnered with a local community program (YMCA) that provided nutritional classes at the health center not only for patients in the HHA program, but also for other health center patients who had a diagnosis of diabetes or maternal hypertension to maximize the number of patients reached with this effort.

At one health center, the NPTMs conducted office hours and nutrition sessions in the existing SMBP monitoring workflow and reported excelling with the program and having very motivated HHA program patients who were actively participating in the lessons. They also provided make-up sessions for the nutrition classes hosted at a local library. Lastly, in another health center, after the healthcare provider referred patients to the HHA program, the NPTMs delivered the office hours at two locations.

Although the health centers experienced challenges in implementing HHA, they also were appreciative of the support and resources provided by the study team and the program’s benefits. They reported that the HHA training was beneficial to educating new staff, and moreover, that the technical assistance calls allowed them to figure out how to re-start distribution of SMBP measurement devices and have processes in place, which ultimately saved them time in the long run.

Conclusion

We delivered the HHA program as an innovation to engage NPTMs (e.g., medical assistants, patient navigators, nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, and social workers) in hypertension management in clinical settings. Health centers welcomed the HHA program with high expectations. Over time, the time commitment required from the clinic staff, staff turnover, and the inability to bill for the services provided as part of the program impacted implementation. These factors decreased health centers’ staff buy-in and hindered the implementation of some of the program components to fidelity. These findings mirror the experiences of clinics in New York, Kentucky, and Missouri who have implemented the HHA curriculum to strengthen their chronic disease management programming [29]. These health centers implemented the program with varying fidelity due to clinic capacity, leadership priorities, and available resources, including the ability to reimburse for services [29].

While FQHCs received grants to support the growth of digital capabilities (e.g., RPM devices, digital storage) associated with telemonitoring care models, reimbursement is needed to sustain them. It is essential for FQHCs to collect and report RPM services they provide, even when not reimbursed, to help support the case for seperate reimbursement for these services.

In conclusion, the HHA program is a potential way to engage NPTMs in hypertension management in clinical settings. However, simply training NPTMs will not suffice- clinics will need ongoing technical assistance to overcome implementation barriers.

Acknowledgements

This report was supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $3.8 million with 100% funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by Texas Department of State Health Services, CDC/HHS, or the U.S. Government.

Author contributions

NIH: conception, design, analysis, interpretation of data, and drafted the manuscript. ERG, FVH, and TLS: design, acquisition of the data, interpretation, and drafting the manuscript. PF helped with the analysis and displays and drafting the manuscript. PDM: design, acquisition of the data, interpretation, editing of the manuscript. MEF: conception, funding acquisition, interpretation of the data, and substantially revising the manuscript. All authors have reviewed and approved the submitted version.

Funding

Funder: Centers for Disease Control and Prevention.

Grant ID: HHS000353700001.

Data availability

Data is available from natalia.i.heredia@uth.tmc.edu upon reasonable request.

Declarations

Ethics approval and consent to participate

This project was approved by the institutional review board at UTHealth Houston (HSC-SPH-21-0180). The need for consent to participate was waived.

Consent for publication

Not Appliable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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