Digital Repository Doctoral Projects Fall 2022 Implementation of Blood Pressure Self-Monitoring Clinic Among Inner City Ogden Residents Claudia Celis Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Celis, C. (2022). Implementation of blood pressure self-monitoring clinic among inner city Ogden residents. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. 1 Implementation of Blood Pressure Self-Monitoring Clinic Among Inner City Ogden Residents by Claudia Celis A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 _______________________________ ______________________________ Claudia Celis, DNP-FNP Student, RN Date _______________________________ _____________________________ Joyce Barra PhD, RN (Electronic Signature) Date _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director 12/16/22 12/16/22 Claudia Celis 12/16/2022 2 Table of Contents Abstract ........................................................................................................................................... 4 Implementation of Blood Pressure Self-Monitoring Teaching Among Inner City Ogden Residents ......................................................................................................................................... 5 Background and Problem Statement ........................................................................................... 5 Diversity of Population and Project Site ..................................................................................... 6 Significance for Practice Reflective of Role-Specific Leadership ............................................. 6 Literature Review and Framework ................................................................................................. 7 Search Methods ........................................................................................................................... 7 Hypertension ............................................................................................................................... 8 Complications ............................................................................................................................. 8 Treatment .................................................................................................................................... 9 Self-Management ...................................................................................................................... 10 At-Home Blood Pressure Self-Monitoring ........................................................................... 10 Medication Management ...................................................................................................... 11 Framework ................................................................................................................................ 11 Discussion ................................................................................................................................. 12 Implications for Practice ........................................................................................................... 12 Project Plan ................................................................................................................................... 12 Project Design ........................................................................................................................... 12 Needs Assessment/Gap Analysis of Project Site and Population ............................................. 13 Cost Analysis and Sustainability of Project .............................................................................. 13 Project Outcomes ...................................................................................................................... 14 Consent Procedures and Ethical Considerations....................................................................... 15 Project Implementation ................................................................................................................. 16 3 Project Intervention ................................................................................................................... 16 Pilot Study Recruiting ........................................................................................................... 16 Initial Consult........................................................................................................................ 16 Education Session One ......................................................................................................... 17 Education Session Two ......................................................................................................... 17 Education Session 3 .............................................................................................................. 18 Exit Interview........................................................................................................................ 18 Project Timeline ........................................................................................................................ 18 Outcome Alignment with Interventions........................................................................................ 18 Project Evaluation ......................................................................................................................... 19 Data Maintenance and Security ................................................................................................ 19 Data Collection and Analysis.................................................................................................... 20 Qualitative Data Analysis ..................................................................................................... 23 Quality Improvement Discussion ................................................................................................. 24 Translation of Evidence Into Practice ....................................................................................... 24 Implications for Practice and Future Scholarship ..................................................................... 25 Sustainability......................................................................................................................... 25 Dissemination ....................................................................................................................... 25 Conclusion ................................................................................................................................ 26 4 Abstract Hypertension is a leading cause of death in the United States. Unfortunately, the asymptomatic nature of this condition leads people to ignore its presence until it becomes severe. Frequently, a lack of understanding of hypertension and a lack of resources make people delay treatment. By receiving adequate education about hypertension self-management, people can become more involved in their health and improve outcomes. Purpose: The Doctor of Nursing Practice (DNP) project was designed to educate people about hypertension and increase participation in their self-management of hypertension. Methodology: The project offered equipment and self-management education to patients during 3-5 meetings. A pre-and post-survey was given to participants to evaluate learning. The survey items reflected a 4-5 Likert scale to assess the participants' confidence in blood pressure self-monitoring. Results: After the implementation, the participants showed a 5.778 average reduction in their systolic blood pressure and a 5.148 point reduction in diastolic blood pressure. The project also found an increased confidence level in overall understanding of hypertension and confidence in taking and recording own blood pressure. Implications for Practice: For best outcomes, when patients are provided with education and tools in the form of a blood pressure monitor, there is an increased chance that the patient will become more engaged in their health and self-management, which may result in improved health outcomes. 5 Implementation of Blood Pressure Self-Monitoring Teaching Among Inner City Ogden Residents The American Heart Association (AHA) has named hypertension "the silent killer" because of its asymptomatic nature, and even when there are symptoms, they are often ignored (AHA, 2017). Having undiagnosed or uncontrolled blood pressure increases the risk of cardiovascular disease mortality (Zhou et al., 2018). Inner-city residents with limited access to healthcare and limited health literacy are at risk of complications from uncontrolled or undiagnosed hypertension. It is estimated that 1 in 4 people have hypertension in Utah (Utah Department of Health, 2020). Some variables contributing to the incidence of undiagnosed or untreated hypertension are race, sex, age, and access to health insurance (Meador et al., 2020). Among ethnic groups, hypertension is more prevalent in Blacks; however, Blacks, Hispanics, and Asian Americans are less likely to have controlled hypertension than Whites (American College of Cardiology & American Heart Association, 2017). Patients with hypertension can achieve improved health outcomes by being involved in their care, receiving adequate patient education, and establishing a personalized care plan with their healthcare provider. When trained and appropriately educated about hypertension self-management strategies, patients are more likely to remain motivated in their treatment (Roy et al., 2021). In addition, identifying patients with unknown hypertension will create opportunities to educate and develop care plans specific to the needs of the patients, which may lead to positive outcomes. Background and Problem Statement In 2017, 25.7% of the population in Utah self-reported having hypertension (Utah Department of Health, 2020). The number of people living with undiagnosed hypertension today is unknown because of the lack of specific symptoms. People living with undiagnosed hypertension are at increased risk of complications related to this condition. These complications 6 include heart disease, stroke, and renal failure, to name a few. A hypertension clinic targeting inner Ogden city residents can identify patients with undiagnosed hypertension and provide the resources needed for treatment and self-management. Diversity of Population and Project Site The United States Department of Health and Human Services (2021) defines an individual annual income of $12,880 as the federal poverty level. In 2019, 17.2 % of the population in Ogden lived in poverty. Next to the white people, Hispanics or Latino are the second largest ethnic group (United States Census Bureau, 2019). In 2014, the median Hispanic household was $39,600, which is 52% lower than the household of non-Hispanic whites. (Velasco-Mondragon et al., 2016). In the United States, Hispanics have lower rates of health insurance enrollment. An explanation could be that 59% of Hispanics perform unskilled, high-risk jobs (Velasco-Mondragon et al., 2016). Job occupations combined with poverty could affect health insurance enrollment rates. The Hispanic community highly populates the east-central region of Ogden. A study by Archer et al. (2019) found that the east-central region of Ogden is a region in need of better information about education opportunities and employment resources. For this project, it is expected that a considerable proportion of patients will be of Hispanic origin as the project site of focus will be east-central Ogden. The main area where the participant intake, education, and treatment will take place is the Weber State Community Education Center. The education center is located in downtown Ogden. It is easily accessible by private vehicle or by bus. Significance for Practice Reflective of Role-Specific Leadership Worldwide, hypertension has been identified as a significant risk factor for stroke and cardiovascular disease (Zhou et al., 2018) (Dubow & Fink, 2011). In the United States, patients with hypertension spend approximately $2,000 annually on healthcare costs related to this 7 condition. National healthcare costs related to hypertension are about $131 billion (Kirkland et al., 2018). Individualized hypertension teaching and self-management strategies can help ease healthcare costs' financial burden on a population with limited resources. Essential II of the American Association of Colleges of Nursing (AACN) (2006) focuses on leadership at an organizational and system level. Doctorate-prepared nurses evaluate the impact of delivery care models and adapt them to specific populations to eliminate health disparities and promote patient safety and healthcare quality. Patient participation and continued engagement level will determine the success of the hypertension clinic. Initiatives like this clinic could serve as a model for future platforms targeted explicitly for this community. Nurse practitioners are in a unique position that prepares them to utilize their most essential core skills, such as communication, to the most specialized, such as leadership, to promote systematic changes. Literature Review and Framework The literature review will aim to define hypertension parameters and explore current treatments and recommendations. The themes of interest for this Doctor of Nursing Practice (DNP) project will be centered around hypertension self-management and medication adherence, particularly among minorities and people of low socioeconomic status. Among the research, there is evidence that blood pressure self-monitoring, patient-centered care, and medication reconciliations have a positive impact on reducing blood pressure (Li et al., 2020) (Matthes & Albus, 2014) (American College of Cardiology & American Heart Association, 2017). This DNP project will seek to apply available literature regarding hypertension management to a specific inner-city community of Ogden, Utah. Search Methods Information for this project was gathered using online databases such as Google Scholar, PubMed, CINAHL, EBSCO, UpToDate, and national organizations like the American Heart 8 Association and the American College of Cardiology. Search words utilized for research included hypertension, risk factors, treatment, outcomes, and self-management. Priority was given to articles that were under ten years old. Hypertension The American College of Cardiology (ACC), in partnership with the American Heart Association (AHA) in their 2016 guidelines for prevention, detection, evaluation, and management of hypertension, assign blood pressure measurements into three categories. A systolic blood pressure of under 120 mm Hg and diastolic lower than 80 mm Hg is considered normal blood pressure. Systolic blood pressure between 120-129 mm Hg and a diastolic under 80 mm Hg is categorized as elevated. Stage 1 hypertension is defined as a systolic blood pressure of 130-139 mm Hg and a diastolic of 80-89 mm Hg on two separate readings within 12 months. Stage 2 hypertension is categorized as having a systolic blood pressure equal to or greater than 140 mm Hg and a diastolic of equal to or greater than 90 mm Hg on one reading within the last 12 months. Unlike many chronic conditions, hypertension can be asymptomatic and go undiagnosed for a long time. While some people may experience dizziness, spotty vision, and headaches, there are no conclusive symptoms of hypertension. As a result, people who experience symptoms will often ignore them (American Heart Association [AHA], 2016). A study by Meador et al. (2018) states that some providers may dismiss a high blood pressure reading as patient anxiety toward health care providers, commonly referred to as "white coat hypertension." Franklin et al. (2013) estimate that white coat hypertension occurs in about 15-30% of patients with elevated blood pressures at the clinic. Complications Hypertension is a precursor to two leading causes of death in the United States, strokes and heart disease. It is estimated that about 50% of the population in the United States has 9 hypertension (Million Hearts, 2021). The risk of cardiovascular disease doubles with every additional 20 mm Hg in systolic blood pressure or with every additional 10 mm Hg in diastolic blood pressure. Similarly, the risk of stroke increases with the increase in blood pressure (Dubow & Fink, 2011). It is not uncommon to find other comorbid conditions among people with hypertension. Hypertension can aggravate angina due to changes in the microvasculature. People with arteriosclerosis can develop peripheral vascular disease due to blood vessel narrowing. Microvascular changes can also negatively affect vision loss and kidney disease in people with these conditions (American Heart Association, 2016). Quality of life among patients with hypertension is correlated to physical function; therefore, one goal of treatment should focus on preventing complications (Soni et al., 2010). Treatment Appropriate hypertension treatment will depend on several factors. The ACC & the AHA (2016) recommend treating stage 1 hypertension (130-139 or 80/89) with medications only if the patient has had a cardiovascular event such as stroke or coronary artery disease or if there is a coexistent condition. Among individuals with stage 1 hypertension who do not have cardiovascular risk factors, the ACC & AHA recommendations are to manage with lifestyle changes. With uncomplicated stage 1 hypertension, providers should consider ruling out white coat hypertension. Ruling out white coat hypertension can be achieved by having the patient monitor and record their blood pressure at home. First-line pharmacological treatment for hypertension includes angiotensin-converting enzyme inhibitors, aldosterone receptor blockers, thiazide diuretics, and calcium channel blockers. For patients that require treatment with more than one medication, combination medications should be considered. An individualized treatment plan will be implemented based on each patient's health history (ACC & AHA, 2016). 10 This DNP project will provide education and treatment for patients classified with either stage 1 or stage 2 hypertension without serious complications. Patients who are found to have complicated hypertension would be immediately referred to a primary care provider. In addition, following ACC & AHA (2016) recommendations, participants in the project will be encouraged to apply lifestyle changes to lower and manage hypertension. Self-Management Nonpharmacological interventions recommended by the ACC & AHA (2016) include physical activity, moderation in alcohol intake, weight loss, and introducing a healthy diet such as the DASH diet. In addition, hypertension self-management improves knowledge about hypertension, increases the ability to recognize profound blood pressure readings, and teaches the patient to self-titrate medications (Li et al., 2020). This project will provide continuous patient support and follow-up for hypertension self-management. A study by Bryant et al. (2020) found that when patients have continued support with hypertension self-management, they are more likely to improve long-term blood pressure outcomes. At-Home Blood Pressure Self-Monitoring Along with using proper technique, the AACN recommends monitoring blood pressure at home as a treatment (ACC & AHA, 2016). Current guidelines by the AHA are to check blood pressure twice a day at the same times of the day for two weeks after any change in therapy (AHA, 2017). At-home blood pressure self-monitoring can aid in diagnosing "white coat hypertension" (Schimbo et al., 2020). Blood pressure self-monitoring has other advantages. Studies have found that blood pressure self-monitoring enhances hypertension self-management as it increases patient confidence with medication management and therefore increases the likelihood of long-term hypertension management (Li et al., 2020)(Bryant et al., 2020)(Schimbo et al., 2020). 11 Medication Management Half of the patients who start hypertension treatment will discontinue taking medications within the first year (Still et al., 2020)(Vrijens et al., 2017). "Medication adherence rates are typically lower among patients of lower socioeconomic status and with racial/ethnic minority backgrounds" (McQuaid & Landier, 2018). Multiple medications and the added costs are the leading reasons why some patients may discontinue taking their medications altogether. Single-pill combination medications have been developed to improve adherence and are encouraged by the ACC & AHA (Vrijens et al., 2017). From a primary care provider standpoint, the "gold standard" is to have at least two evaluation methods when evaluating medication adherence. These evaluation methods include pill counts, electronic databases, self-report forms, and questionnaires (Anghel et al., 2019). Metthes & Albus (2014) found that simplification of medication schedules, shared decision-making between patients and providers, and appropriate medication selection based on individual factors such as income and side effects are strategies that have been proven to improve medication adherence. Framework Havelock's Theory is an appropriate change theory to implement in setting up a hypertension clinic for patients who are currently undiagnosed or untreated. Havelock's Theory focuses on the planning and monitoring of change, which is the project's focus. During the project's planning stages, a target population has been identified, and the needs of this community are evaluated. Havelock's Theory follows six steps: building relationships, diagnosing a need for change, securing resources, selecting the best response, implementing the difference, and maintaining and stabilizing the change or project (Finkelman, 2022). During this project, a relationship with the participants will be established as the team seeks to individualize a care plan for each patient identified with hypertension. A decision will be made between providers and patients to determine and set a reachable goal of treatment. 12 Participants in the project will receive teaching, medications, and a blood pressure cuff to facilitate patient engagement and self-management. The participants will then be followed up via telemedicine, phone calls, and in-person meetings to ensure that patients continue to have the resources for successful at-home self-monitoring. Discussion Patients who can self-manage hypertension are more likely to lower and maintain appropriate hypertension readings long-term (Li et al., 2020)(Bryant et al., 2020)(Schimbo et al., 2020). Implementing a hypertension clinic among inner-city Ogden residents will increase hypertension awareness in the community. Facilitating hypertension education and self-management resources with regular follow-ups during four months could set the path for the successful long-term management of hypertension for inner-city residents. Implications for Practice Hypertension often goes undiagnosed due to a lack of apparent symptoms. Patients with undiagnosed hypertension are in danger of developing life-threatening conditions. Hypertension can be prevented and treated, but barriers to health access, education, and finances affect the likelihood of patients seeking treatment. The hypertension clinic will provide DNP students insight into common barriers that inner-city residents experience. The knowledge gained from this project will enable DNP students and the local Health Department to better understand and manage hypertension among underserved populations. Project Plan Project Design This clinic is a quality improvement project that directly affects the population of the city of Ogden. The IRB for the Hypertension Clinic, as a whole, is submitted as a pilot study. However, the education portion of the project will be designed as four in-person/zoom monthly classes where the participants will receive additional information about hypertension self-13 management. During these meetings, the project participants will be encouraged to ask questions and voice any concerns. Additionally, during these meetings, data from their blood pressure log trackers will be collected and uploaded into the electronic health record. Needs Assessment/Gap Analysis of Project Site and Population The Hispanic population is one of the largest ethnic minorities in the United States. Unfortunately, Hispanics are less likely to have controlled hypertension, especially women (Elfassy et al., 2020)(Guzman, 2012). Guzman (2012) states that only 38% of Hispanic women (Mexican-American) with hypertension can reach normal blood pressure when treated. In Utah, the incidence rate of hypertension among Hispanics is relatively equal to the incidence rate among non-Hispanic citizens (Utah's Public Health Data Resource, 2020). Access to health care, poverty, language barriers, and education level are among the factors that could negatively affect the health of the Hispanic population (U. S. Department of Health and Human Services, 2019). Health care initiatives targeting health literacy and management may improve the population's health outcomes. Cost Analysis and Sustainability of Project A $40,000 grant was awarded to the Department of Health Education at the Weber-Morgan Health Department. The money was used to purchase the participant supplies and office supplies for the distribution of education materials. Weber State University was instrumental in providing laboratory services, office space, and personnel. A budget plan is attached (see Appendix A). The sustainability plan will involve implementing the same program with adjustments if funding is granted in the future. Any identified community health issues will be addressed during the following program implementation. A continued partnership between the Health Department and Weber State University can provide opportunities for future DNP projects within this same 14 hypertension program. Additionally, a continued partnership will allow for improved development and implementation of the hypertension program based on previous experiences. The participants will be able to keep the blood pressure cuff and fitness tracker provided during the program. These tools and the knowledge on how to use them will help the patients continue working toward their blood pressure goals. In addition, one of the outcomes of the Hypertension program will be to transfer patient care to a primary care provider. Once patients have been involved in their care, have the tools for self-management, and have access to a primary care provider, they will be more likely to continue to be engaged in their care. Project Outcomes The program's immediate goal will be to reduce the participants’ systolic and diastolic blood pressure. The overarching goal of this program is to identify people with undiagnosed hypertension. It is estimated that 75 million Americans have hypertension, and 11 million have uncontrolled hypertension because they do not know their blood pressure is high enough to need treatment (Million Hearts, 2021). Even if patients decide not to participate in the program, they will at least receive information regarding hypertension, and they will be encouraged to follow up with their primary care provider. Once patients have signed consent and are willing to participate in our project, a short-term goal will be to keep patients engaged in their care. Participants will be in contact with the project coordinators and community health workers every two-three weeks during the duration of the project. The participants will be contacted by phone or text, whichever is preferred, and they will be encouraged to ask questions or bring up any concerns. The participants will also be reminded about upcoming hypertension classes via their preferred method of communication. To promote engagement, patients will receive gift cards that can be used at the local grocery stores, which will help facilitate access to healthy food options. 15 The project's primary long-term goal from the self-management aspect will be for participants to continue monitoring their blood pressure even when their care is transferred to a primary care provider. The participants will have to receive education on continuing to take their medications, if applicable, and continue to take their blood pressure with the blood pressure cuff provided by the Weber-Morgan Health Department and Weber State University. In continuing self-management, the participants will be able to see the effects that medications and lifestyle changes have on their blood pressure. Consent Procedures and Ethical Considerations Institutional Review Board (IRB) approval was submitted and approved on November 23, 2021. The IRB was introduced as a pilot study that will include quality improvement education on controlling and managing hypertension. The IRB application included a copy of the consent form that was provided to the clinic participants (see Appendix B). Patients from all backgrounds have the right to equal, high-quality care, however, several factors can stand in the way. Access to health insurance and hypertension unawareness has been described by Norris (2016) as determinants contributing to uncontrolled hypertension. In addition, sociodemographic characteristics and health literacy have been identified as factors contributing to hypertension self-management (Lor et al., 2019). Language and cultural barriers are other factors that can contribute to inefficient patient-provider communication, which can affect the quality of care a Hispanic patient might get compared to a non-Hispanic white. The clinic will address some of these determinants of health by using bilingual community health workers from the Weber-Morgan Health Department, who will help make sure Spanish and English-speaking participants understand the consent form information. The hypertension clinic also seeks to improve health literacy relating to hypertension by providing four in-person classes. 16 Project Implementation Project Intervention The implementation process involved an individual intake session for which instruction on how to measure their blood pressure was given in English or Spanish, depending on the participant's preferred language. Then, three subsequent monthly education sessions were offered in person or via Zoom. The education materials for these meetings were PowerPoint presentations, pamphlets, or single-sheet handouts in English or Spanish. Finally, a last in-person, individual meeting was scheduled in which the participants filled out a post hypertension survey that would aid the project's evaluation process. Pilot Study Recruiting The project implementation occurred after the pilot study recruited participants at local events within inner-city Ogden. Recruitment took place between September 2021-January 2022. The recruitment sites included: Ogden Farmers Market, Rancho Market, Catholic Community Services, and downtown Ogden's Hispanic Festival. During the recruiting process, participants had their blood pressure measured by the Weber-Morgan Health Department's staff and members of Sigma Theta Tau who were found to have elevated blood pressure (SBP equal to or greater than 130, or DBP equal or greater than 80), were presented with hypertension education materials and information about the hypertension clinic. The participants who decided to enroll in the study were then asked to set up an intake consult with a Nurse Practitioner, Cathy Harmston FNP, who would assess and initiate hypertension treatment if needed. Initial Consult Individual intake consults took place between January 12 – February 12. A collaboration between Cathy Harmston, FNP, Weber State University's Laboratory Science students, and Weber State University's personnel was required to meet small groups of participants. At the initial consult with Cathy Harmston, FNP, patients had a second blood pressure measurement 17 that established the diagnosis of hypertension. Subsequently, participants had their blood drawn as a part of a complete physical exam. At this meeting, participants who had signed consent and had labs and assessments done were provided with various education pieces. The education covered how to measure blood pressure at home using an automatic blood pressure monitor (Appendix C). A tracking sheet (Appendix D) was provided where the participants would write down daily blood pressures for two weeks and then weekly for twelve more weeks. Education Session One The first education session took place at the Weber State University Community Education Center on January 26, 2022. The time allotted for this session was one hour. Participants could join either in person or via a Zoom meeting. As a part of hypertension self-management, a PowerPoint presentation (Appendix E) given by a DNP student was used to review hypertension pathophysiology and risk factors, identify high blood pressures, and return demonstrate checking their blood pressure for the DNP student to determine successful self-monitoring. Participants were asked to bring their blood pressure trackers to this meeting so they could be reviewed and entered into the electronic health record. The meeting was planned to last from 6:00 pm until 7:00 pm. The participants were there on time, and the presentation did not extend beyond the scheduled time. There were 10 in-person participants and one who joined via Zoom that attended the meeting, all of whom preferred the information to be given in Spanish. Education Session Two Session 2 took place on February 26, 2022. Again, participants could participate either in person or via Zoom meeting. Due to space availability, this meeting was done at the Weber-Morgan Health Department. Once again, participants were asked to bring their hypertension trackers for review. During this session, which lasted an hour, education about medication adherence (Appendix F), sodium consumption, and physical activity was addressed by 18 PowerPoint Presentation (Appendix G). 17 participants attended in person, and four joined via Zoom for this meeting. Education Session 3 Education Session 3 took place at the Weber-Morgan Department of Health on March 23, 2022. The topic covered during this meeting was the importance of setting up a primary care provider for the long-term management of hypertension and setting goals for the future. Other information covered was a review of when it would be appropriate to continue monitoring their blood pressure after the project's conclusion (Appendix H). This last meeting was scheduled to last from 6:00 pm until 7:30 pm. The last 30 minutes were used to congratulate and show appreciation to the participants for attending all the education sessions. During this time, participants signed up for one of two days in which they will have their labs redrawn, and the project’s FNP will perform a final physical exam. Exit Interview Two days were scheduled to perform final labs and a physical exam. These days were April 4, 2022, and April 9, 2022. During this in-person meeting, patients were asked to fill out a post-Hypertension clinic survey (Appendix L). In addition, the participants were notified that their medical records from this project would be mailed to their home addresses. The participants signed consent to release their medical records to themselves. Project Timeline The project was implemented over the course of three months. Participants were seen in person 5-6 times. In-person meetings involved intake, lab collection, education, and an exit interview. A brief overview of the project timeline is presented in Appendix I. Outcome Alignment with Interventions During the recruitment process, some participants with previously undiagnosed hypertension were identified. Other participants knew they had hypertension but did not have the 19 resources to manage this condition. The project intervention met the outcome of identifying people with undiagnosed or undertreated hypertension. Participants received education, treatment, and resources to manage hypertension. The project recruited 30 participants, and of those, 27 attended all of their meetings. The participants turned in blood pressure readings with each education session, proving their engagement in their care. Another indicator of engagement was their participation in all of the education sessions. By receiving information regarding how to measure blood pressure and the importance of health engagement and having a primary care provider, the participants are equipped with what they need to continue to manage their blood pressures beyond this project. Project Evaluation There were 30 participants who were recruited to participate in this project. Of these participants, 27 completed the project. For this project, the participants were seen in person a total of five times throughout the implementation process. The participants completed a pre-hypertension clinic survey during their initial visit and a post-hypertension clinic survey on their last visit. Portions of the survey were reflected on a 5-point Likert scale to evaluate the participants' concerns regarding their apprehension about their blood pressure and their understanding of the impact of hypertension on their health. Other segments of the survey reflected the participants' confidence regarding understanding and self-monitoring high blood pressure on a 4-point Likert scale. Data Maintenance and Security Participant data was secured within an electronic health record purchased for the implementation period of the project. A project coordinator secured project data in the form of paper surveys and consent forms. The data was stored in a locked drawer at Weber State University. Some participants were able to enter their survey responses directly into SurveyMonkey using an assigned participant number. 20 Data Collection and Analysis During the recruitment phase of the project, the pre-hypertension clinic survey had not been developed as a SurveyMonkey form; therefore, a paper version was provided to all participants. At the end of the project, participants were given the option to submit an online SurveyMonkey version of the post-hypertension survey or to complete a paper version. In the end, all surveys were input into SurveyMonkey by the project coordinator and two Weber- Morgan Health Department Community Health Workers. Table 1 Participant Demographics Demographic description n % Gender Male 11 40.74% Female 16 59.26% Ethnicity White 10 35.71% Hispanic 18 64.29% African American 1 3.51% Education level Some high school 6 22.22% Less than high school 3 11.11% Completed high school 9 33.33% Some college or technical school 5 18.52% Completed technical school/associates' degree 2 7.41% Completed B.A. or B.S. degree 2 7.41% Note. N=27 Participants. Participants' median age was 55 years Of the 27 participants that completed the program, 11 were male, and 16 were female. Hispanics represented 64.29% of the participants. The majority of participants, 66.66%, finished high school. Table 2 Blood Pressure Readings Post Hypertension Clinic Values Average reduction 95% CI p 21 Systolic Blood Pressure 5.778 -10.402 – -1.154 0.016 Diastolic Blood Pressure 5.148 -7.857 – -2.498 0.001 Reduction of systolic and diastolic blood pressures post hypertension clinic are significant with p-scores of 0.016 and 0.001respectively. Table 3 Pre-Hypertension Clinic Survey Findings of Hypertension Concern and Understanding Description Statement Strongly Agree or Agree Unsure Strongly Disagree or Disagree n % n % n % I am concerned about my blood pressure 23 85% 1 4% 2 7% I understand the impact that high blood pressure can have on my health 20 74% 3 11% Table 4 Post-Hypertension Clinic Survey Findings of Hypertension Concern and Understanding Description Statement Strongly Agree or Agree Unsure Strongly Disagree or Disagree n % n % n % I am concerned about my blood pressure 19 70% 1 4% 7 26% 22 I understand the impact that high blood pressure can have on my health 27 100% Note. N=27 Participant concern about their blood pressure decreased from 85% pre-hypertension clinic to 70% post-hypertension clinic. This can be due to reduced systolic and diastolic blood pressures and/or increased confidence in knowledge about hypertension. In addition, the participant understanding of the impact of hypertension also rose from 74% pre-hypertension clinic to 100% post-hypertension clinic. Table 5 Pre-Hypertension Clinic Participant Confidence Level Survey Description Statement Very confident Confident A little confident Not at all n % n % n % n % How confident are you in your overall understanding of hypertension? 3 11% 9 33% 6 22% 3 11% How confident are you in taking your blood pressure and recording it? 6 22% 13 48% 2 7% 1 4% Note. N=27 Table 6 Post-Hypertension Clinic Participant Confidence Level Survey Description Statement Very confident Confident A little confident Not at all n % n % n % n % 23 How confident are you in your overall understanding of hypertension? 11 41% 14 52% 2 7% How confident are you in taking your blood pressure and recording it? 16 59% 9 33% 2 7% Note. N=27 The participants' confidence in overall understanding of hypertension increased particularly among the very confident and confident ranges. Similarly, participant confidence in taking and recording their blood pressure also increased among the same ranges of very confident and confident. Qualitative Data Analysis The post-hypertension clinic survey (Appendix L) filled by the participants included the question "What did you like most about this program?". An abbreviated content analysis of the responses was done by two DNP students and a Weber State University faculty member, over three Zoom meetings. The common themes in the responses were feeling cared for, knowledge, and community. Participant comments such as: "The information was great, the people are very helpful," "Everyone was wonderful to work with," and, liking "the attention and kindness of the personnel…" were among the common responses to this question. The last question on the post-hypertension clinic survey was to provide any comments about the program. It was found that sustainability was also a common theme. Comments like: "Really enjoyed the program and hope there is more" and "grateful for this program, hope to participate in others" were examples that support this theme. 24 Quality Improvement Discussion Responses from the participants demonstrated increased confidence in their overall understanding of hypertension, understanding of the impact of hypertension on their health, and confidence in monitoring and recording their blood pressure. With the statement "I am concerned about my blood pressure" the majority of participants, representing 85%, agreed or strongly agreed that they were concerned in the pre-hypertension clinic survey. In the post-hypertension survey, a reduction of 70% of participants agreed or strongly agreed that they were concerned about their blood pressure. An explanation for this decrease is that the participants could lower their blood pressure to a value comfortable to them. Another explanation could be that after the program, participants felt empowered with the knowledge necessary to continue to decrease their blood pressure. Participant confidence levels increased with their overall understanding of hypertension and confidence in taking their blood pressure and recording it. In the pre-hypertension survey, 11% of participants did not feel confident at all in their understanding of hypertension, and 4% did not feel confident monitoring their blood pressure. However, on the post-hypertension confidence level survey, all participants had at least some confidence in their overall understanding of hypertension and taking and monitoring their blood pressure. Translation of Evidence Into Practice Based on the comments from the participants, it was evident that by providing participants with the tools that enable them to record and keep track of their blood pressure, it is possible to see reductions in blood pressure. In addition to the ability to maintain a blood pressure log, the participants of the project demonstrated interest and an increased engagement in their care. These findings can be interpreted as a need for more community-based resources for patients with hypertension. 25 Implications for Practice and Future Scholarship If able to maintain the funding and collaboration between the Weber-Morgan Health Department and Weber State University, this program can be the starting point in implementing more community-based programs. The development of new programs or the continuation of this hypertension clinic provides opportunities for future DNP students to expand and improve community education related to hypertension and associated comorbidities. Sustainability The funding for the continuation of this hypertension clinic has not been secured as of now, nor has the continued partnership between the Weber-Morgan Health Department and Weber State University. However, the Weber-Morgan Health Department has kept a record of the PowerPoint presentations and education materials developed by the DNP students who participated in the hypertension clinic implementation. Currently, there is a planned set of three hypertension education classes open to the community offered by the Weber-Morgan Health Department, where the information shared during these classes will be the same as the information covered by the hypertension clinic. One of the DNP students who participated in the implementation of the hypertension clinic has volunteered to continue the smaller-scale hypertension education classes to be offered this fall by the Weber-Morgan Health Department to the community. Dissemination The DNP students who participated in the implementation of the hypertension clinic will be featured in the 2021-2022 Weber State University Annual Report. The piece talks about the hypertension clinic and the participation of these students. Presentation of findings by way of a professional publication is still a consideration. 26 Conclusion After the DNP project, an average decrease in systolic and diastolic blood pressure of at least 5 mmHg was seen in this group of participants. Based on pre-and post-hypertension clinic surveys, participants reported increased confidence in monitoring and recording their blood pressures. These findings can increase the chances that these participants will continue to be involved in the long-term management of hypertension. A common theme noted from participant comments was sustainability and community. This represents an excellent opportunity for future DNP students to expand and improve this program. Additionally, there was a perceived need and interest from the participants for more community programs like these. 27 References Anghel, L. A., Farcas, A. M., & Oprean, R. N. (2019). An overview of common methods used to measure treatment adherence. Medicine Pharmacy Report, 92(2), 117-122. doi: 10.15386/mpr-1201. American Association of Colleges of Nursing (AACN) (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf American College of Cardiology & American Heart Association. 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(2018). Uncontrolled hypertension increases the risk of all-cause and cardiovascular disease mortality in US adults: the NHANES III linked mortality study. Scientific Reports, 8(1), 9418. https://doi.org/10.1038/s41598-018-27377-2 32 Appendix A Community-Based Hypertension Project (10/5 updated) List of Itemized Supplies and Budget: Cost Center: based on • 30 patients: 20 lifestyle education only + 10 with lifestyle education and medication prescription • For 3 months (12 weeks) Amount Totals PERSONNEL $8000 Nurse Practitioner. (Dr. Cathy Harmston) Per hour: $75/ hour • N=20 lifestyle education only: o Week 1 (intake) = 60 mins. + Week 3 (follow-up) = 30 mins.+ Week 7 (follow-up) = 30 mins. +Week 11 (final intake)= 30 mins. o Total per person = 2.5 hours each X 20 = 50 hours o 50 hours X $75 = $3750 • N= 10 requiring medication management + lifestyle education o Week 1 (intake) = 60 mins. + Week 3 (follow-up) = 45 mins.+ Week 5 = 30 mins. + Week 7 (follow-up) = 30 mins. + Week 11 (final intake)= 30 mins. o Total per person = 3.25 hours each X 10 = 50 hours o 50 hours X $75 = $3,750 Other: Team meetings; orienting to EHR; consultation with other members; team meeting; = $500 Total= $3,750 $3,750 $500 $8,000 SUPPLIES $17,850 Clinic Office Supplies: • Screen/privacy • Computer (on loan) • 3 Tablets/Samsung Galaxy A7 @ Costco $200 X3= $600 • Printer (on loan from WSU) • BP cuff (purchase X 1) @ $150 • Stethoscope (providers usually have their own) • Otoscope (Health Assessment tools) (on loan from WSU) • Weight Scale @ $40 Patient Records and Documentation • Electronic Health Record (EHR) system o For health records and patient's surveys o RXNT: Cloud-Based, Integrated Healthcare Software X12months = $1020 $600 $150 $40 $1020 33 Program/Project Supplies= approximate $2000 paper, printing? Pamphlets/Brochures Subtotal= $2000 $3,810 Patient Toolkit for 30: • BP cuffs : electric/automatic upper arm o 25 Omron 5 wireless series (Model BP7250) @ Walmart o $50 X 25= $1250 o 5 Omron 5 series donated • Fitness trackers: heart rate; track; o (30) Xiaomi 6 @ Walmart o $50 X 30 = $1500 • Food Vouchers/ Gift cards for groceries (incentive) o $25 per month X 3 months= $75 X 30 = $2250 • Incentive reward for completing the program (incentive) o Fitbit 2 watch o (20) X $95 =$1,425 • Containers for toolkits and water bottles o $25 X 30 = $750 • Cookbook/s o $15 X 30 = Recruiting • Swag (100X $10) =$1000 • Tent/Canopy (on loan) • Banner ($100) • Chairs (on loan) • Table (on loan) • BP cuffs (on loan from WSU) Subtotal= $1250 $1500 $2250 $1,900 $750 $450 $1000 $100 $9,200 Lab Test and Equipment N= 50; 30 pre survey's and 20 post surveys • Labs: Lipid and CMP Panels =$1,610 • Equipment (paper, pipets, sponges, bandages, tubes, needles etc.) • Undercounter Refrigerator @ $3,000. Subtotal= $1610 $230 $3000 $4,840 OTHER $4,800 34 Transportation: For patient's to clinic (20) X $15 = $300 For team to residents? Patient Prescriptions: Unable to pay Medication prescriptions= $500 Working with local pharmacy? Dissemination Activities Professional Conference Presentation for 2 team members Travel/Registration $2000 each X 2 = $4000 Subtotal= $300 $500 $4000 $4,800 TOTAL $30,650 Personnel Supplies Other TOTAL $8000 $17,850 4,800 $30,650 35 Appendix B WEBER STATE UNIVERSITY INFORMED CONSENT Implementation of a Community-Based Hypertension Program: A Pilot Study You are invited to participate in a research study intended to serve the greater Ogden community members who have hypertension (high blood pressure). You were selected as a possible subject because your blood pressure was higher than it should be at two different times. Your top number (systolic) pressure is higher than 120 (>120), and/or the bottom number (diastolic) is 80 or higher (>80). You also told the person taking your blood pressure that you were interested in taking action to improve your blood pressure and overall health and you live within the Ogden community. We ask that you read this form and ask any questions you may have before agreeing to be in the study. The study is being conducted by Mary Anne Reynolds, Ph.D., RN, ACNS-BC and Catherine Harmston, DNP, FNP-BC from Weber State University, and Annette Prall, MHA from Weber-Morgan Health Department. This program is funded by a grant from the Utah Department of Health. STUDY PURPOSE: The purpose of this study is to: 1. Identify members of the Ogden community who have high blood pressure; 2. Perform a health assessment; 3. Provide community-based resources that will support lifestyle changes and self-management relating to high blood pressure and being healthy; and if needed, prescribe medication; and 4. Link participants with primary care providers or clinics to provide long-term care. This study does not involve the use of any investigational drugs or devices. NUMBER OF PEOPLE TAKING PART IN THE STUDY: If you agree to participate, you will be one of 30 people participating in this research. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will be asked to do the following things. 1. On your first in-person visit, you will be asked to complete three patient surveys before a health care provider sees you. The surveys will ask you about you and your health and your health-related activities. 2. You will then have a health assessment by a nurse practitioner. The assessment will include a health history, a physical exam, and a blood sample. a. You will be asked not to eat or drink for 12 hours before your blood draw appointment. There will be a small stick with a needle, and one tube of blood will be collected at your first and last visits by a trained lab person (phlebotomist). This will be used to check your heart risk. 3. At this visit, you will be given a blood pressure gift bag that includes your own blood pressure cuff. You will be taught how to take and write down your blood pressure. This first visit will take approximately 1 ½ hours. You will also see the nurse practitioner three more times. Two of the visits may be in person or over video conferencing. The last visit will be in person, and a blood sample will be drawn once more. 4. In addition, over the next 11 weeks, you will be participating in education and activity classes every 2-3 weeks. The programs will teach you about high blood pressure (hypertension), healthy eating, and how to be physically active. You will be taught how to take your blood pressure, heart rate, weight, and other activities and how to record it. This information will be given to the nurse practitioner and 36 recorded every one to two weeks. The5 educational classes will take approximately 3 hours total. In addition to the classes, you will be asked to engage in physical activity (like walking) for about 20-25 minutes 3-4 times per week for a total of 1-2 hours per week. 5. Not everyone in the study will need pills or medication to control their blood pressure. If you do need medication, you will see the nurse practitioner one additional time. RISKS OF TAKING PART IN THE STUDY: There are several possible risks to being part of this study that include: 1. When answering questions about your health, your health behaviors, and your family's health, you might feel uncomfortable. All efforts will be made to keep your personal information confidential and private. 2. As you increase your physical activity, you may feel sore and tired for a short time. 3. During in-person visits with research team members, there will be close contact that has risks, but all study personnel will be vaccinated and wearing appropriate masks and protective equipment. 4. If medications are required, possible side effects will be discussed by the nurse practitioner. 5. Common risks associated with taking your blood include bruising or bleeding or tenderness where the needle went in. Other risks include possible infection, numbness, tingling, or pain. Please tell us if it hurts or feels funny. BENEFITS OF TAKING PART IN THE STUDY: You will not be paid for taking part in this study. However, there are several benefits to being part of this study. 1. You will be seeing a health care provider (nurse practitioner) at least four times with no cost to you. The provider will give you important information about your current health. 2. You will learn about high blood pressure and the things you can do to help make it lower. 3. You will learn about how to take care of other problems related to having high blood pressure over time with ideas on what to do. 4. You will learn how to take care of your blood pressure through healthy eating and activity that will, over many years, help you stay healthy. 5. You will get your own blood pressure cuff and an activity tracking watch that you can keep. You will also be given a monthly, $25 grocery gift card for 3 months that will help in buying healthy foods. 6. At the end of this study, an appointment will be made (you will be referred) to a health provider or clinic that will work with you over a long period of time. ALTERNATIVES TO TAKING PART IN THE STUDY: Instead of being in the study, you have the option to, at ANY time during the study, you can go to your own doctor or health care provider. COSTS /COMPENSATION FOR INJURY: There is no cost to you except your time and any specific and personal exercise equipment you buy to help you exercise. In the event of physical injury resulting from your participation in this research, necessary medical treatment or help will be provided to you and billed as part of your medical expenses. Costs not covered by your health care insurer will be your responsibility. Also, it is your responsibility to determine the extent of your health care coverage. There is no program in place for other monetary compensation for such injuries. However, you are not giving up any legal rights or benefits to which you are otherwise entitled. If you are participating in research which is not conducted at a medical facility, you will be responsible for seeking medical care and for the expenses associated with any care received. 37 CONFIDENTIALITY: Efforts will be made to keep your personal information confidential-so others do not know you are part of the study. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports in which the study may be published and databases in which results may be stored. Organizations that may inspect and/or copy your research records for quality assurance and data analysis include groups such as the study investigator and his/her research associates, the Weber State University Institutional Review Board or its designees, and (as allowed by law) state or federal agencies, specifically the Office for Human Research Protections (OHRP) and the Food and Drug Administration (FDA) [for FDA-regulated research and research involving positron-emission scanning], the National Cancer Institute (NCI) [for research funded or supported by NCI], the National Institutes of Health (NIH) [for research funded or supported by NIH], etc., who may need to access your medical and/or research records. CONTACTS FOR QUESTIONS OR PROBLEMS: For questions about the study, contact Mary Anne Reynolds, at (801) 626 6161 or Cathy Harmston, at (801) 626 6368 at Weber State University. For questions about your rights as a research participant or to discuss problems, complaints or concerns about a research study, or to obtain information, or offer input, contact the Chair of the IRB Committee IRB@weber.edu. VOLUNTARY NATURE OF STUDY: Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with Weber State University, Weber-Morgan Health Department, or the Utah Department of Health. If you do withdraw from this study before completion, it could pose a risk to you if your blood pressure is not controlled. Poorly controlled hypertension could result in poor health. It would be recommended that you seek out a health provider. SUBJECT'S CONSENT: In consideration of all of the above, I give my consent to participate in this research study. I will be given a copy of this informed consent document to keep for my records. I agree to take part in this study. Subject's Printed Name: Subject’s Signature: ___________________________________________Date: __________ (must be dated by the subject) Printed Name of Person Obtaining Consent: Signature of Person Obtaining Consent:____________________________Date: If the study involves children who will be providing their assent on this consent document, rather than on a separate assent document, use the following signatures: Printed Name of Parent: Signature of Parent:_______________________________________________Date: 38 Appendix C 39 Appendix D Hypertension Tracker Check and Record at the same time every day for two weeks your: BLOOD PRESSURE, HEART RATE, WEIGHT, ACTIVITY, & DIET After 2 weeks you may start recording your blood pressure, heart rate, and weight only once a week. Week & Day Date and time Blood Pressure Heart Rate Weight Type of Activity # of Minutes or # steps Dietary protein and sodium Are you taking your medications WEEK 1 day 1 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 2 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 3 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 4 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 5 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 6 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 7 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds WEEK 2 day 8 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds 40 day 9 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 10 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 11 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 12 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 13 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds day 14 / ____ # of steps ____ # of min Protein: Sodium: ___yes___ no ___ no meds WEEK 3 / ___ times/week ___ # week Protein: Sodium: ___yes___ no ___ no meds WEEK 4 / ___ times/week ___ # week Protein: Sodium: ___yes___ no ___ no meds WEEK 5 / ___ times/week ___ # week Protein: Sodium: ___yes___ no ___ no meds WEEK 6 / ___ times/week ___ # week Protein: Sodium: ___yes___ no ___ no meds WEEK 7 / ___ times/week ___ # week Protein: Sodium: ___yes___ no ___ no meds WEEK 8 / ___ times/week Protein: Sodium: ___yes___ no 41 ___ # week ___ no meds WEEK 9 / ___ times/week ___ # week Protein: Sodium: ___yes___ no ___ no meds WEEK 10 / ___ times/week ___ # week Protein: Sodium: ___yes___ no ___ no meds WEEK 11 / ___ times/week ___ # week Protein: Sodium: ___yes___ no ___ no meds WEEK 12 / ___ times/week ___ # week Protein: Sodium: ___yes___ no ___ no meds 42 Appendix E 43 Appendix F 44 45 46 Appendix G 47 48 Appendix H 49 50 51 Appendix I Initial Encounter 1st Education Session 2nd Education Session 3rd Education Session Exit Interview Jan 12-Feb 12 January 26 February 23 March 23 April 4 and April 9 Record a second elevated BP Draw labs Assessment by NP Patient receives BP cuff with instructions of use Patient return demonstrates checking a blood pressure Pre hypertension clinic survey Review on what is hypertension Review and recognize normal values vs elevated values. Review blood pressure trackers Return demonstrate checking a blood pressure Brief review of hypertension Hypertension treatment Importance of medication use Tips to improve medication adherence Importance of patient-provider communication Importance of having a PCP for long term management Provide a list of providers accepting new patients within the area Exit labs Final physical exam by FNP. Post hypertension clinic survey 52 Appendix J PATIENT DEMOGRAPHICS Are you?  Male  Female  _______________ What is your birthdate? Month: __________ Day: __________ Year: __________ Age: _____ What is your race/ethnicity? (Check all that apply)  African American or Black  American Indian or Alaskan Native  Asian  Hispanic or Latino/Latina  Native Hawaiian/Other Pacific Islander  White  ______________________________ What is the highest level of education you have completed?  Less than high school  Some high school  Completed high school or G.E.D.  Some college or technical school  Completed technical school/associate's degree  Completed B.A. or B.S/ degree  Graduate study/advanced degree(s) What is your current employment status?  Employed full-time (35 hours a week or more)  Employed part-time (less than 35 hours a week)  Not currently employed  Retired  _____________________ What is your current marital status?  Single, never married  Married,  Committed relationship  Separated  Divorced  Widowed How many adults and children live in your household, including yourself? _____ adults (>18 years old) live in my household _____ children (<18 years old) live in my household 53 What is your total household income in the past 12 months from all sources? Please include income earned by you and other members of your household.  Less than $10,000  $10,000-$19,999  $20,000-$29,999  $30,000-$39,999  $40,000-$49,999  $50,000-$59,999  $60,000-$69,999  $70,000 or moreHYPERTENSION SELF-MANAGEMENT 1 Health History Questions Do you currently carry health insurance?  Yes: Who are you insured by or what is the name of your insurance? ________________  No Who do you usually see for your health needs (Primary care provider)? __________________ When was the last time you were seen by a medical person? ___________________________ What clinic or office do you usually go to? ___________________________________________ What pharmacy that you usually go to? ______________________________________________ Where do you usually shop for food? ______________________________________________ Focused Health History Do you smoke or use tobacco? □ Yes: how many cigartettes/tobacco per day? When did you start to smoke or use tobacco? ____ □ No Does anyone in your home smoke? □ Yes □ No Do you drink alcohol? □ Yes □ No If yes, how often do you drink alcohol? □ Less than once a month □ Less than once a week □ 1-3 times per week □ 3-7 times per week Have you ever used recreational drugs? □ Yes □ No Have you ever abused prescription drugs? □ Yes □ No Do you or a family member have a history of: Cancer:  I have/had cancer  My family member/s who has had cancer is: _________ Diabetes: HYPERTENSION SELF-MANAGEMENT 2  I have/had diabetes  My family member/s who has had diabetes is: _________ Heart Disease:  I have/had heart disease  My family member/s who has had heart disease is: _________ Stroke:  I have/had a stroke  My family member/s who has had a stroke is: _________ Kidney Disease:  I have/had kidney disease  My family member/s who has had kidney disease is: _________ Blood Pressure Questions Have you ever been told that your blood pressure was high? □ Yes □ No If yes: When were you told (how long ago)? __________________________________________ Who or where were you told that your blood pressure was high? _____________________ What was done about your blood pressure (check all that apply)?  Nothing more was said  I was told to watch it and see if it got better  I was told to exercise more  I was told to change my diet  I was started on medication. The name of the medication was? ________  I have been working with my doctor to treat my blood pressure HYPERTENSION SELF-MANAGEMENT 3 Appendix K PRE-HYPERTENSION READINESS TO CHANGE SURVEY B PR1. I am concerned with my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree PR2. I want to improve my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree PR3. My life will be the same, even if I improve my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree PR4. I am willing to take medicine to improve my blood pressure if I need to □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree PR5. I am willing to change my eating habits to improve my blood pressure if I need to □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree PR6. I am willing to exercise more to improve my blood pressure if I need to □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree HYPERTENSION SELF-MANAGEMENT 4 PR7. I understand the impact that high blood pressure can have on my health. □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree PR8. How confident are you in your overall understanding of hypertension? □ Very confident □ Confident □ A little confident □ Not at all PR9. How confident are you in taking your blood pressure and recording it? □ Very confident □ Confident □ A little confident □ Not at all PR10. How confident are you in planning a heart-healthy meal? □ Very confident □ Confident □ A little confident □ Not at all PR11. How confident are you that you will be able to exercise regularly? □ Very confident □ Confident □ A little confident □ Not at all HYPERTENSION SELF-MANAGEMENT 5 Appendix L ID No: ______ https://www.surveymonkey.com/r/2DYNNLK POST-HYPERTENSION READINESS TO CHANGE SURVEY B (POST-R) 1. POST-R 1.I am concerned with my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree 2. POST-R 2. My blood pressure is improving □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree 3. POST-R 3. My life is the same, even as I improve my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree 4. POST-R 4. I am taking medicine to improve my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree 5. POST-R 5. I am changing my eating habits to improve my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree HYPERTENSION SELF-MANAGEMENT 6 6. POST-R 6. I am exercising more to improve my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree 7. POST-R 7. I understand the impact that high blood pressure can have on my health. □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree 8. POST-R 8. How confident are you in your overall understanding of hypertension? □ Very confident □ Confident □ A little confident □ Not at all 9. POST-R 9. How confident are you in taking your blood pressure and recording it? □ Very confident □ Confident □ A little confident □ Not at all 10. POST-R 10. How confident are you in planning a heart-healthy meal? □ Very confident □ Confident □ A little confident □ Not at all 11. POST-R 11. How confident are you that you can exercise regularly? □ Very confident □ Confident HYPERTENSION SELF-MANAGEMENT 7 □ A little confident □ Not at all HEALTH ASSESSMENT SURVEY (HPOST: P0ST-HA) Well-Being 13. HPOST 1. Rate your overall well-being □ Great □ Good □ Fair □ Poor □ Bad 14. HPOST 2. Rate your overall health: □ Great □ Good □ Fair □ Poor □ Bad 15. HPOST 3. How safe do you feel? □ Very □ Not Very □ Not at all 16. HPOST 4. How satisfied are you with your life? □ Very □ Not Very □ Not at all 17. HPOST 5. How often do you feel depressed? □ Always □ Often □ Occasionally □ Never Nutrition 18. HPOST 6. How many daily servings of vegetables do you eat? □ None □ 1-2 HYPERTENSION SELF-MANAGEMENT 8 □ 3-4 □ 5-6 □ more 19. HPOST 7. How many daily servings of fruit do you eat? □ None □ 1-2 □ 3-4 □ 5-6 □ more 20. HPOST 8. How many daily servings of grains do you eat? □ None □ 1-2 □ 3-4 □ 5-6 □ more 21. HPOST 9. How many daily servings of meat/protein do you eat? □ None □ 1-2 □ 3-4 □ 5-6 □ more 22. HPOST 10. How many daily servings of sugar/carbohydrates do you eat? □ None □ 1-2 □ 3-4 □ 5-6 □ more Exercises 23. HPOST 11. What type of physical activity do you like to do? □ Walking □ Aerobic workout □ Running/jogging □ Bicycling HYPERTENSION SELF-MANAGEMENT 9 □ Swimming □ None □ Other 24. HPOST 12. How many days per week do you do physical activity/exercise? □ None □ 1-2 □ 3-4 □ 5-6 □ More □ inconsistently 25. HPOST 13. Length of time spent on physical activity/exercising each day? □ None □ Less than 20 minutes □ 20-29 minutes □ 30-60 minutes □ More than 60 minutes 26. POST 14. Do you have any injuries or conditions that interfere with your exercising? □ Yes; please list the injury/condition/s:_____________________ □ No 27. HPOST 15. How many hours of sleep do you get per night?: _____ 28. HPOST 16. How restful is your sleep? □ Very □ Somewhat □ Not Very Stress 29. HPOST 17. On average, how stressed do you feel in everyday life? □ Super stressed □ Moderately stressed □ Slightly stressed □ Stressed □ Not stressed HYPERTENSION SELF-MANAGEMENT 10 30. HPOST 18. Do you believe that your stress level can be improved? □ Yes □ No □ Unsure 31. HPOST 19. How do you cope with everyday stress? □ I don't □ Exercise □ Spend time outdoors □ Video games or social media □ Sleeping □ Other: ____________________ 32. HPOST 20. What would you say causes the most stress in your everyday life? □ Family □ Financials □ The news □ Job □ Other: ___________ 33. P1. Overall, This blood pressure program made good use of my time: □ Strongly agree □ Agree □ Neither agree or disagree □ Disagree □ Strongly disagree 34. P2. What did you like most about this program? 35. P3. Any other comments: