Digital Repository Doctoral Projects Fall 2022 Primary Care Hypertension Management in Older Adults: Incorporating New Guidelines and Effective Follow-up into the Hear the Beat Program Ryan G. Davis Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Davis, R. G. (2022). Primary Care Hypertension Management in Older Adults: Incorporating New Guidelines and Effective Follow-up into the Hear the Beat Program 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. Primary Care Hypertension Management in Older Adults: Incorporating New Guidelines and Effective Follow-up into the Hear the Beat Program by Ryan G. Davis 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 Project Consultant: Quincy Robinson, MPA, MA Project Consultant: Sarah Gadd, FNP-C 12/16/22 Ryan G. Davis, DNP-FNP Student, RN Date 12/16/22 Date 12/16/22 Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Note: The program director must submit this form and paper. Kelley Trump, DNP, MSN/Ed, RN, CNE, COI Faculty Project Lead MANAGING HYPERTENSION WITH HEAR THE BEAT 2 Table of Contents ABSTRACT ...................................................................................................................................................................................... 3 INTRODUCTION ............................................................................................................................................................................ 4 BACKGROUND AND PROBLEM STATEMENT ...................................................................................................................................... 5 DIVERSITY OF POPULATION AND PROJECT SITE ................................................................................................................................ 6 SIGNIFICANCE FOR PRACTICE REFLECTIVE OF ROLE-SPECIFIC LEADERSHIP ...................................................................................... 7 LITERATURE REVIEW AND FRAMEWORK ........................................................................................................................... 8 SEARCH METHODS ......................................................................................................................................................................... 8 SYNTHESIS OF LITERATURE ............................................................................................................................................................. 8 Lifestyle Modification for Management and Prevention .......................................................................................................... 9 Home-Based Blood Pressure Monitoring .............................................................................................................................. 10 Utilization of Mobile Health ................................................................................................................................................. 11 Education on Consequences of Unmanaged HTN ................................................................................................................ 12 Aggressive HTN Treatment for Adults 65 and Older............................................................................................................. 12 FRAMEWORK ............................................................................................................................................................................... 14 Identify Triggering Issues/Opportunities ............................................................................................................................... 14 Clinical Applications............................................................................................................................................................. 14 State the Question or Purpose .............................................................................................................................................. 15 Topic Priority ....................................................................................................................................................................... 15 Form a Team ........................................................................................................................................................................ 16 Assemble, Appraise, and Synthesize Body of Evidence ......................................................................................................... 16 Sufficient Evidence ............................................................................................................................................................... 17 Design and Pilot the Practice Change .................................................................................................................................. 17 Decide if the Change is Appropriate for Practice ................................................................................................................. 17 Integrate and Sustain the Practice Change ........................................................................................................................... 18 Disseminate Results .............................................................................................................................................................. 18 DISCUSSION ................................................................................................................................................................................ 19 IMPLICATIONS FOR PRACTICE ....................................................................................................................................................... 19 PROJECT PLAN .......................................................................................................................................................................... 20 PROJECT DESIGN ......................................................................................................................................................................... 20 NEEDS ASSESSMENT OF PROJECT SITE AND POPULATION .............................................................................................................. 21 COST ANALYSIS AND SUSTAINABILITY OF PROJECT ....................................................................................................................... 21 PROJECT OUTCOMES.................................................................................................................................................................... 22 CONSENT PROCEDURES AND ETHICAL CONSIDERATIONS ............................................................................................................... 22 INSTRUMENTS TO MEASURE INTERVENTION EFFECTIVENESS ......................................................................................................... 23 PROJECT IMPLEMENTATION ................................................................................................................................................ 25 PROJECT INTERVENTION .............................................................................................................................................................. 25 PROJECT TIMELINE ...................................................................................................................................................................... 26 PROJECT EVALUATION............................................................................................................................................................ 27 DATA MAINTENANCE/SECURITY .................................................................................................................................................. 27 DATA COLLECTION AND ANALYSIS .............................................................................................................................................. 28 FINDINGS .................................................................................................................................................................................... 28 Strengths ............................................................................................................................................................................... 31 Weaknesses ........................................................................................................................................................................... 32 QUALITY IMPROVEMENT DISCUSSION ............................................................................................................................... 33 TRANSLATION OF EVIDENCE INTO PRACTICE................................................................................................................................. 33 IMPLICATIONS FOR PRACTICE AND FUTURE SCHOLARSHIP ............................................................................................................. 33 Sustainability ........................................................................................................................................................................ 34 Dissemination ....................................................................................................................................................................... 34 CONCLUSION ............................................................................................................................................................................... 35 REFERENCES .............................................................................................................................................................................. 37 APPENDICES ............................................................................................................................................................................... 43 MANAGING HYPERTENSION WITH HEAR THE BEAT 3 Abstract Purpose: Primary care providers can improve hypertension (HTN) management by using the Hear the Beat (HTB) pamphlet to guide the comprehensive management of HTN, especially for older adults. The 2020 International Society of Hypertension Global Hypertension Practice Guidelines provide updated blood pressure (BP) parameters and encourage greater patient participation. The HTB pamphlet needed revision to comply with the latest guidelines. The Doctor of Nursing Practice (DNP) team modified the pamphlet and created training on updates for clinical staff at the Ogden Clinic – Farmington family practice and urgent care. Methodology: Clinical staff completed a pre-education survey and were educated on the updated HTB pamphlet. Next, the staff completed a post-education survey and utilized the pamphlet for two months. Finally, a post-implementation survey was given. A questionnaire was given to patients two weeks after receiving HTB so that Ogden Clinic’s quality department staff could determine the usefulness of the updates. Qualitative and quantitative data were gathered, with most on a Likert scale or Yes/No/Unsure. Results: Data analysis revealed an increase in HTB usage by clinical staff. Staff members also improved in defining national BP parameters and explaining home BP tracking. Patient responses showed a universal belief that the HTB pamphlet is helpful. In addition, 93.75% of patients agreed that their knowledge and frequency of home BP monitoring increased. Over 80% saw a BP improvement. Implications for practice: These results indicate that HTB is a clinical tool capable of managing HTN and is preferred by staff and patients. Keywords: hypertension, older adult, guidelines, mobile health, follow-up MANAGING HYPERTENSION WITH HEAR THE BEAT 4 Primary Care Hypertension Management in Older Adults: Incorporating New Guidelines and Effective Follow-up into the Hear the Beat Program Despite modern advancements in medicine and emerging clinical tools, resources, and technologies to treat hypertension (HTN), an estimated 50% of hypertensive patients do not adequately control the disease (Reboussin et al., 2018). Though general awareness of HTN has improved in recent years, the global burden of the disease has increased substantially (Forouzanfar et al., 2017). HTN leads to cardiovascular, renal, and cerebrovascular disease. No other condition is more tied to disability and premature death (Mills et al., 2016). Elevations in systolic blood pressure (SBP) are frequently associated with early death caused by ischemic heart disease, hemorrhagic strokes, and ischemic strokes (Forouzanfar et al., 2017). Improved management of the disease process will reduce the disease burden of HTN and significantly decrease healthcare costs associated with emergent care and waste. More importantly, it will save and improve the lives of patients, old and young. Older adults, especially those of lower socioeconomic status, have significantly higher rates of HTN than their younger counterparts (Mills et al., 2016). Nearly one of every four community-dwelling adults aged 65 or older in the United States has fair or poor overall health (Centers for Disease Control and Prevention [CDC], 2021). Many of these older adults have HTN and other comorbidities that require comprehensive primary care management but do not receive adequate care or follow-up. Primary care coordination for older adults is worse in the United States than in other high-income countries (Penm et al., 2017). In addition to their age, this lack of management and follow-up for older adults places them at greater risk for complications of HTN. MANAGING HYPERTENSION WITH HEAR THE BEAT 5 Primary care providers (PCPs) are responsible for identifying, managing, and providing follow-up HTN care for all patients. PCPs routinely screen for HTN, educate on lifestyle and diet modification, and present various treatment options for hypertensive patients. The 2020 global HTN practice guidelines authored by the International Society of Hypertension (ISH) and published by the American Heart Association (AHA) provide new parameters for target BP readings (Unger et al., 2020). SBP is considered “normal” under 130 mmHg, “high-normal” between 130-139 mmHg, “Grade 1 HTN” between 140-159 mmHg, and “Grade 2 HTN” when greater than or equal to 160 mmHg. Current guidelines recommend diligent HTN treatment and follow-up care to mitigate disease risks in all ages (Unger et al., 2020). The primary purpose of this project is to advocate for all patients to receive more comprehensive HTN management and follow-up, especially older adults. Updating the Hear the Beat (HTB) clinical tool and creating a training for Ogden Clinic – Farmington’s clinical staff will improve staff understanding of the tool and mobile health, facilitate their utilization, and eventually lead to decreased SBP of the clinic’s patients. Background and Problem Statement Quality indicators have identified a gap in the screening, treatment, and follow-up of HTN in Davis County, UT. Many local community-dwelling older adults have HTN despite various available healthcare and community resources. After being seen in the clinic, these older adults require structured, dedicated follow-up and education by clinical staff to achieve an SBP under 140 mmHg. HTN management is crucial in elderly individuals with comorbidities such as coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, or a previous stroke (Unger et al., 2020). Reducing the SBP to this level has shown significance in decreasing the risk of hospitalization for preventable and treatable conditions precipitated by MANAGING HYPERTENSION WITH HEAR THE BEAT 6 HTN. Ogden Clinic has an HTB clinical tool to address essential education and follow-up aspects of HTN treatment. However, most clinical staff are unfamiliar with the pamphlet, and the information included does not incorporate the most recent HTN guidelines (Q. Robinson, personal communication, May 17, 2021). In addition, the HTB tool also does not have recommendations for practical follow-up methods, such as using the patient portal. Updating the HTB program and educating the clinic’s staff on these updates may increase the utilization of the tool to help all patients, regardless of age, achieve BP within normal limits. Diversity of Population and Project Site Davis County, UT, is home to a large number of community-dwelling older adults. Statistics published in 2017 showed 328,714 adults aged 65 and older residing in the county (Office of Health Care Statistics, 2017). Ogden Clinic – Farmington is one of several primary care clinics located in the county that serves this population. In 2020, the clinic saw 16,942 patients (Q. Robinson, personal communication, April 13, 2021). Adults aged 65 or older totaled 11.17% of the patients seen. Approximately 17% of all patients seen in 2020 had at least five diagnosed chronic health conditions, such as diabetes, chronic heart and pulmonary disease, and HTN. The clinic’s patients are generally well-insured, and 11% of the clinic’s patients are on Medicare. The clinic serves primarily White (91%) and Hispanic (4%) patients (Q. Robinson, personal communication, June 22, 2021). The clinical staff of Ogden Clinic – Farmington that interacts with hypertensive patients consists of two medical doctors (MDs), a family nurse practitioner (FNP), four medical assistants, and a unit clerk. Each physician sees approximately 30 patients a day, and the FNP sees about 12-17 patients a day (Q. Robinson, personal communication, April 13, 2021). A training on the updated HTB program will encourage its use among these staff members, and a recording of the training will help any additional staff, such as new medical assistants, other MANAGING HYPERTENSION WITH HEAR THE BEAT 7 providers, students completing residency hours at the clinic, laboratory technicians, and practice managers to be familiar with the tool. In addition, updates to the HTB tool make it more applicable to the patient population that the clinic serves, especially older adult patients. Significance for Practice Reflective of Role-Specific Leadership The Doctor of Nursing Practice (DNP) prepared FNP is well-positioned to lead patient- centered HTN management and follow-up. DNP-FNPs are leaders in the clinic, frequently making care more patient-centric, equitable, and comprehensive. Outside of the clinic, the DNP- FNP focuses on leadership in politics, education, and the public health sector. The DNP-FNP politically advocates for the profession to be allowed to practice to the full scope of their expertise in areas they are currently restricted, such as the ordering and provision of cardiac rehabilitation services (American Association of Nurse Practitioners [AANP], 2019). The DNP- FNP educates on evidence-based guidelines such as those written by the ISH to improve HTN management and follow-up. DNP-FNPs engaged in this project exemplify an essential element of their training as they “provide leadership for evidence-based practice…[in] the translation of research in practice, the evaluation of practice, improvement of the reliability of health care practice and outcomes, and participation in collaborative research” (American Association of Colleges of Nursing [AACN], 2006, p. 11). The management and follow-up of HTN support the DNP-FNP’s public health role by aiming to ultimately reduce the prevalence, complications, and hospitalizations due to HTN in Davis County (Counsell et al., 2009). MANAGING HYPERTENSION WITH HEAR THE BEAT 8 Literature Review and Framework This literature review intended to identify best practices for the management and follow- up of HTN and incorporate them into the HTB program. In addition, the review analyzed the newest HTN guidelines published by the International Hypertension Society and considered their incorporation in program updates. These guidelines and other resources suggest HTN management and follow-up include: (a) lifestyle modification for BP control and prevention, (b) home-based monitoring, (c) utilization of mobile health (i.e., patient portal), (d) education focusing on the consequences of unmanaged HTN, including nonadherence to pharmacological therapies, and (e) aggressive treatment even for adults aged 65 or older. The IOWA Model Revised: Evidence-based Practice to Promote Excellence in Health Care framework guided the DNP project. Search Methods Databases used included Google Scholar and CINAHL Complete: Nursing and Allied Health. References included in the guidelines were also reviewed. Search terms included hypertension, older adults, geriatrics, elderly, primary care, guidelines, value-based care, screening, mobile health, and patient portal. The search included articles discussing home or clinic-based health management interventions or follow-up. Additional inclusion criteria were that the article discussed care for elderly patients at least 60 years of age. Articles were excluded if greater than 12 years old, if the article’s focus was residents of long-term care, or if the authors primarily wrote in a language other than English. Synthesis of Literature Many studies have associated a lack of sufficient HTN management and follow-up with various complications and consequences. These consequences include severe damage to the MANAGING HYPERTENSION WITH HEAR THE BEAT 9 cardiovascular and renal systems, dissecting aortic aneurysm, eclampsia, myocardial infarction, stroke, disability, and death (Mills et al., 2016; Reboussin et al., 2018; Whelton et al., 2018). Preventable hospitalization and institutionalization are significantly associated with HTN (Counsell et al., 2009; Hennein et al., 2018; Tilea et al., 2018). In addition, significant rises in healthcare costs result from undertreated HTN (Hennein et al., 2018; Whelton et al., 2018). The literature review identified many risk factors for HTN that met the search criteria. These risk factors included comorbidities, older age, genetic disorders, lower income, lower levels of education, and a weak patient-provider relationship (Beery et al., 2018; Mills et al., 2016; Schoenthaler et al., 2017; Tilea et al., 2018; Whelton et al., 2018). While articles differed in content and recommendations for HTN management and follow-up, the literature consistently suggested that HTN is far too prevalent and that care gaps exist in primary care. In the United States, an estimated one-third of adults older than 20 and nearly two-thirds of adults over 60 have HTN (Brashers, 2019). Despite being treatable, HTN is the most prevalent primary diagnosis in the country. Rates in low- and middle-income countries are almost three times as high (Mills et al., 2016). Various themes emerged in the literature to address this care gap. Primary care providers are more effective in HTN management when they (a) focus on lifestyle modification for the control and prevention of elevated BPs, (b) encourage home-based monitoring, (c) facilitate the utilization of mobile health like the patient portal, (d) educate on the consequences of unmanaged HTN, emphasizing nonadherence to pharmacological therapies, and (e) engage in aggressive treatment of HTN even for older adults. Lifestyle Modification for Management and Prevention The most recent HTN guidelines describe lifestyle modifications as the primary means of HTN prevention (Unger et al., 2020; Whelton et al., 2018). Though previous HTN guidelines MANAGING HYPERTENSION WITH HEAR THE BEAT 10 recognize many of the same lifestyle modifications, the 2020 International Society of Hypertension Global Hypertension Practice Guidelines definitively designate lifestyle modification as the first-line antihypertensive intervention and include other categories for lifestyle changes not included in previous guidelines. These additional categories include “healthy drinks,” “complementary, alternative, or traditional medicines,” and “reduce exposure to air pollution and cold temperature” (Unger et al., 2020, p. 1342). In addition, universally accepted lifestyle modifications for HTN prevention and management include weight loss, a healthy diet, reduced sodium intake, sufficient potassium intake, physical activity, and moderation in alcohol consumption (National Heart, Lung, and Blood Institute [NHLBI], n.d.; Unger et al., 2020; Whelton et al., 2018). Home-Based Blood Pressure Monitoring Recent literature strongly suggested the value of home-based BP monitoring and other self-care measures for HTN management. Home-based BP monitoring effectively identifies white coat and masked HTN and encourages greater patient involvement in their care (Hanley et al., 2013; Reboussin et al., 2018; Unger et al., 2020; Whelton et al., 2018). Home-based BP monitoring can be an even more effective tool in managing HTN and improving follow-up when readings are communicated back to the provider through a telemonitoring system (Hanley et al., 2013). Stoddart et al. (2013) performed a randomized controlled trial (n = 401) among hypertensive primary care patients, finding that self-BP monitoring with a telemonitoring service capable of transmitting readings back to the provider is more effective at reducing BP. Though the study found the intervention beneficial for patients and providers, it also resulted in an up- front cost significantly greater than traditional care (p <0.001). However, despite the possibility MANAGING HYPERTENSION WITH HEAR THE BEAT 11 of increasing initial expense, Patmon et al. (2016) found that patient engagement in interactive healthcare technologies results in decreased long-term care costs. Utilization of Mobile Health Telehealth methods such as mobile phones for monitoring and communication have shown promise in helping patients manage chronic conditions (Beck et al., 2017; Whelton et al., 2018). Some consider mobile health the most promising method of patient engagement (Tietze & Brown, 2019). In addition, the most recent guidelines recognize mobile phones’ potential as adherence aids (Unger et al., 2020). Beck et al. (2017) conducted a randomized controlled trial of older patients (n = 97) living at home with Parkinson’s Disease and found that using telehealth for virtual home-based follow-up visits was feasible, beneficial, valuable, and preferred by patients. Such telehealth and mobile health can improve quality of life, increase adherence to treatment plans, and save patients and caregivers time and money. Patient Portal. Of mobile health technologies available to assist with BP management and follow-up, the patient portal is perhaps the most secure and best for direct patient-provider communication for all patients. Patient portals allow patients to become more engaged in managing their chronic conditions and generating their health-related data while simultaneously sharing it with their providers (Deering et al., 2013; Gee, 2020). In addition, patient portals assist patients and providers in improving communication and developing mutual trust in managing conditions like HTN (Gee et al., 2015). MANAGING HYPERTENSION WITH HEAR THE BEAT 12 Education on Consequences of Unmanaged HTN Educating patients on the risks and consequences of unmanaged HTN has been recognized as a vital component of HTN management that significantly affects adherence to a treatment plan (Tan et al., 2017; Tilea et al., 2018; Whelton et al., 2018). Older adults are at particular risk for poorly managed HTN. Older adults often have comorbidities, lapses in adherence, and declines in cognitive function that affect their ability to effectively manage their BP (Hennein et al., 2018). Education is more effective when accompanied by additional resources, including printed materials, to assist the patient and family in remembering instructions (Whelton et al., 2018). Nonadherence To Pharmacological Therapies. Failure to adhere to a medication regimen significantly contributes to unmanaged HTN (Hennein et al., 2018; Tan et al., 2017; Tilea et al., 2018; Unger et al., 2020; Whelton et al., 2018). For example, Tan et al. (2017) conducted a phenomenological qualitative study among low-income hypertensive patients in Malaysia (n = 17). They found that poor understanding of pharmacological agents and their side effects negatively impacts adherence. In addition, a quantitative cross-sectional, descriptive study conducted by Tilea et al. (2018) found that better adherence to medications resulted in better BP control and a decreased cardiovascular risk (p = 0.02) in hypertensive patients of a family practice clinic in Romania (n = 525). Aggressive HTN Treatment for Adults 65 and Older Care gaps have been identified in HTN management in older adult patients, despite guidelines stating that intensive treatment reduces cardiovascular risk in this population (Penm et al., 2017; Vetrano et al., 2018; Whelton et al., 2018). Though community-dwelling residents aged 65 and older in the United States have higher access to primary care than older adults in MANAGING HYPERTENSION WITH HEAR THE BEAT 13 many other countries, nearly one in four have fair or poor overall health (CDC, 2021). Penm et al. (2017) analyzed data from the 2013 Commonwealth Fund International Health Policy survey results of adult primary care patients (n = 13,958) from 11 countries. They found that rates of primary care coordination were most lacking in the United States. Furthermore, a systematic review and meta-analysis performed by Vetrano et al. (2018) found that many older adults are hypertensive and suffer from frailty, placing them at greater risk for hospitalization, institutionalization, poor clinical outcomes, and death. One of the few treatments that improve outcomes for these frail individuals is following clinical guidelines for HTN management and follow-up. In addition to an aggressive plan of care in the clinic and at home, older adults that engage in community-based HTN programs and education benefit from increased prevention, knowledge, and self-care (Ozoemena et al., 2019; Whelton et al., 2018). Ozoemena et al. (2019) conducted a quasi-experimental quantitative study (n = 400) among African retirees aged 60 years old or older that found that community-based educational program consisting of HTN videos, discussions, and a booklet significantly increased HTN knowledge and self-care practices including: (a) physical activity (p = 0.007), (b) sleep pattern and quality (p = 0.003), (c) substance use abstinence (p < 0.0001), (d) healthy diet (p < 0.0001), (e) medication adherence (p < 0.0001), and (f) home BP monitoring (p < 0.0001). Though the latest guidelines had some minor adjustments for target BP in elderly patients with specific comorbidities, interventions need not differ significantly for these individuals compared to their younger counterparts (Unger et al., 2020; Whelton et al., 2018). MANAGING HYPERTENSION WITH HEAR THE BEAT 14 Framework The Iowa Hospitals and Clinics created The IOWA Model: Evidence-based Practice to Promote Excellence in Health Care in the 1990s to apply new research to patient care (Titler et al., 2001). While the basics of the model remain, the Iowa Hospitals and Clinics have since enhanced and revised this model. The Iowa Model Collaborative (2017) outlines the components of the revised model as (a) identify triggering issues/opportunities, (b) clinical applications, (c) state the question or purpose, (d) topic priority, (e) form a team, (f) assemble, appraise, and synthesize a body of evidence, (g) sufficient evidence, (h) design and pilot the practice change, (i) decide if the change is appropriate for practice, (j) integrate and sustain the practice change, and (k) disseminate results. The components of this revised model guided the DNP project, serving as a framework for planning and implementation. Identify Triggering Issues/Opportunities Half of those diagnosed with HTN do not reach adequate control (Reboussin et al., 2018). Individuals aged 65 years or older are at increased risk for poor clinical outcomes associated with HTN (Vetrano et al., 2018). The DNP team identified inconsistencies in staff knowledge about the HTB program, leading to incongruous approaches to HTN management for their patients. This triggered a quality improvement project that included updating the HTB pamphlet, educating staff, and empowering staff to take a more evidence-based approach to HTN management. Clinical Applications The clinical application of training on HTN care and follow-up utilizing the HTB pamphlet occurred when the clinical staff was presented with the education and began implementing the suggestions in their practice. This application entailed clinical staff using the MANAGING HYPERTENSION WITH HEAR THE BEAT 15 updated HTB pamphlet in patient education and follow-up. Eventually, the clinical application by the clinic staff will cause a decrease in the SBP of hypertensive patients. The project also focused on using mobile health, including the patient portal, to follow up with patients on their BP management and support them in home-based BP monitoring. Because this project challenged traditional practice and focused on improving the clinical staff’s management of a life-threatening condition, it was considered clinically relevant (Dang et al., 2019). State the Question or Purpose The purpose statement of the project had clear boundaries and involved critical elements. These elements included defining the clinical problem, the intended population, and the pilot area (Dang et al., 2019). The question the student compiled for the DNP project was: “Will the clinical staff at Ogden Clinic – Farmington increase their utilization of the HTB program after receiving training on the updated program when compared to no training over two months?” This step of the revised Iowa Model kept the team focused on a specific target and prevented deviation from the intended purpose. Topic Priority Identifying HTN as a priority topic was essential to utilizing the revised Iowa Model. If HTN was not a priority for the organization, the DNP project might not have been worth its resources. Organizations prefer topics that deal with the safety of patients, are costly, or align with the organization’s mission (Dang et al., 2019). For example, the management of HTN deals directly with patient safety, as untreated or undertreated HTN is known to lead to significant cardiovascular disease, serious cardiovascular events, disability, and death (Whelton et al., 2018). In addition, unmanaged HTN is costly, with better management of the condition being one of few interventions probable to significantly decrease healthcare costs (Counsell et al., MANAGING HYPERTENSION WITH HEAR THE BEAT 16 2009). Lastly, the clinic prioritized this topic as BP management carried out with more outstanding excellence, dedication, and compassion aligned with Ogden Clinic—Farmington’s mission. Form a Team Forming a team ensured interprofessional involvement and the inclusion of team members with skill sets specific to the project (Iowa Model Collaborative, 2017). In addition to the student, the DNP project team involved (a) the clinic’s Senior Practice Administrator, who had extensive knowledge of training clinical staff and the functions of the clinic, (b) an FNP with experience in managing BP and performing follow-up care, and (c) an expert DNP team faculty lead experienced in patient care, education, and applying evidence-based practice. The Senior Practice Administrator was familiar with the HTB pamphlet and provided it as a resource for HTN management and follow-up. Additionally, the Senior Practice Administrator facilitated communication with various stakeholders. Assemble, Appraise, and Synthesize Body of Evidence The DNP team assembled, appraised, and synthesized available evidence supporting HTN management using the revised Iowa Model (Dang et al., 2019). First, the student determined the focus for the DNP project and assembled evidence on effective HTN management. Next, the DNP team appraised the literature to ensure the project goals aligned with the most recent evidence from validated sources. Finally, the team synthesized the evidence to determine the gaps in clinical care compared to the research. Throughout the DNP project, the team completed further research to ensure the project remained focused on the most recent evidence available. MANAGING HYPERTENSION WITH HEAR THE BEAT 17 Sufficient Evidence After assembling, appraising, and synthesizing the evidence, the team evaluated whether the evidence gathered was sufficient for determining a change in practice (Dang et al., 2019). If not, the team planned to shift their focus to gathering evidence from related topics. Because HTN management and follow-up have long been a topic of evidence-based practice, current evidence was considered sufficient. In addition, the most recent revisions to published guidelines were used to ensure the plan for HTN management and follow-up included the latest evidence (Reboussin et al., 2018). Design and Pilot the Practice Change Next, the revised Iowa Model involved designing and piloting the practice change while utilizing gathered evidence (Dang et al., 2019). This phase applied outcomes of controlled research studies in the accessible clinical setting. For this phase of the DNP project, the DNP team developed a mock presentation, and a small group of clinical staff tested it before other staff members received the training. This pilot presentation included visual resource drafts on the HTB pamphlet’s recommended updates. The team gathered input on the pilot program, making necessary adjustments before the presentation to all end-users. Decide if the Change is Appropriate for Practice Input from the pilot helped the DNP team determine whether the change was appropriate for rollout into practice (Dang et al., 2019). After the research and creation of the mock presentation, the team decided that clinical staff and patients would benefit from the actual updates to the HTB program. If the team had determined that the updates and presentation were not beneficial, the project would have been forfeited or redesigned. Throughout this and all other MANAGING HYPERTENSION WITH HEAR THE BEAT 18 phases of the revised Iowa Model, team members remained current on any new HTN research developments or knowledge. Integrate and Sustain the Practice Change After completing all previous revised Iowa Model steps, the DNP team and clinical staff integrated the change into practice (Dang et al., 2019). The change included the team developing a sustainability plan, identifying local champions, and gathering additional senior leaders’ support. For this phase, the student presented in a staff meeting to current staff members. After completing the training and allowing two months of incorporating recommendations, staff members filled out a brief survey to determine the benefit of the DNP project for staff and patients. Staff members passionate about the training were asked to be local champions of the practice change and to emphasize its importance to others, especially future staff. These champions facilitated the dissemination of the change among current and future clinical professionals. Disseminate Results The last step of the revised Iowa Model included disseminating the results of the DNP project outside of the organization to support the growth of the evidence-based practice, the expansion of nursing knowledge, and the encouragement of additional change (Dang et al., 2019). Since the DNP project succeeded in all other stages of the revised Iowa Model, the updated HTB pamphlet and a recorded version of the presentation were recommended to other Ogden Clinic locations, starting with two additional clinics. In addition, Ogden Clinic’s quality department director stated that changes found beneficial to the clinic can be disseminated in the future through the Ogden Clinic Family Medicine Department to other Ogden Clinic locations. MANAGING HYPERTENSION WITH HEAR THE BEAT 19 Discussion The literature on HTN management and follow-up spanned various interrelated topics associated with applying the latest HTN guidelines. Possible limitations of this literature review included the restricted generalizability of the data to all primary care locations and variations in the ages of study subjects. The review’s strengths included a wide variety of considerations for HTN management and the application of research to address the needs of a specific patient population at risk for a care gap. In general, sample sizes and settings were sufficient for the topic application. The literature presented data objectively, though it did not generally explore the benefits of continued traditional care. Additional research is needed to comprehensively compare all factors of applying a similar intervention to conventional care. Implications for Practice Evidence supports using a clinical tool like the HTB pamphlet for more active HTN management and follow-up in the primary care setting. Other similar interventions and tools have proved helpful in lowering SBP and increasing the self-care that patients engage in (Ozoemena et al., 2019). Revised guidelines necessitate revised interventions in primary care to provide care at the highest level of quality and safety in HTN management and follow-up. MANAGING HYPERTENSION WITH HEAR THE BEAT 20 Project Plan The project plan consisted of five main phases. Consistent with the revised IOWA Model, these phases were planning, pilot, implementation, evaluation, and dissemination. The planning phase consisted of updating the HTB pamphlet with the most recent HTN guidelines, designing the pamphlet, meeting with the DNP team on feedback, and organizing project deliverables for the training. The pilot phase consisted of a test presentation to the Ogden Clinic – Farmington staff to obtain staff feedback, finetune the HTB pamphlet and follow-up methods, finalize project deliverables according to end-user input, and obtain Institutional Review Board (IRB) approval. The project's implementation phase involved (1) training clinical staff on current HTN guidelines, the updated HTB pamphlet, and methods of follow-up, (2) administering the pre-implementation survey, (3) contacting staff who missed training, and (4) checking with staff on questions regarding pamphlet usage. The evaluation phase included an ongoing review of feedback from clinical staff on the pamphlet’s content, design, and follow-up methods, administering and analyzing the post-implementation survey, and analyzing the results of the staff-conducted follow-up surveys to gauge patient benefit. Lastly, the dissemination phase of the project consisted of sharing a recorded version of the training and copies of the pamphlets to the Davis Family Physicians and Grand View Ogden Clinic locations and contacting the Family Medicine Department for approval of the pamphlet for all Ogden Clinic locations. Project Design The DNP project focused on providing education for process and practice intervention improvement at Ogden Clinic. Updating the HTB pamphlet to include the most recent HTN guidelines was a process improvement, while educating staff on these changes led to improved MANAGING HYPERTENSION WITH HEAR THE BEAT 21 practice interventions. Better patient HTN care and follow-up lead to better clinical outcomes (Tan et al., 2017; Tilea et al., 2018; Whelton et al., 2018). Needs Assessment of Project Site and Population The project focused on a direct and an indirect population. The direct population was the clinical staff at Ogden Clinic – Farmington. While the staff had a previous version of the HTB pamphlet, most staff were unaware of the booklet or the most recent HTN guidelines. Therefore, the staff needed education on the booklet and the updates made following the 2020 guidelines. The indirect population affected by the project was the clinic’s patients that received care from the staff, especially the community-dwelling older adults with chronic health conditions and those that presented to the clinic with HTN. This population has been identified as at greater risk for HTN and poor primary care management (Penm et al., 2017; Vetrano et al., 2018). Cost Analysis and Sustainability of Project Expenses for the project are relatively small and can be broken down into categories of staff, graphics work, and printing. For initial project implementation, the projected cost was $260 (see Appendix A). However, the actual price was much less than this as staff training occurred during previously established staff meetings during lunch breaks and did not require overtime. In addition, the graphics work was done by Ogden Clinic’s Graphic Design Communication Specialist, who is a paid employee and was given sufficient time to finish the pamphlet design during work hours. Printing the updated pamphlets cost approximately $100, which Ogden Clinic covered. In addition, the student donated treats for staff who participated in the training at no expense. The three-year continuation budget for sustaining the project is estimated at a maximum of $1,700 for Ogden Clinic, including costs for reimbursing staff, graphics work, and printing the MANAGING HYPERTENSION WITH HEAR THE BEAT 22 pamphlet one additional time if new HTN guidelines are released in the next two years (see Appendix B). Continual training of clinical staff will cost an estimated $1,500 over three years, including expenses for staff, presentations, and any treats, drinks, and prizes. The continual efforts of clinical staff to educate patients on the HTB pamphlet could cost an estimated maximum of $3,870, including costs for printing new booklets, rewards, and staff time for patient follow-up. Project Outcomes The outcomes of the project were to improve (1) staff understanding of current HTN guidelines, (2) staff usage of the HTB pamphlet, and (3) staff HTN follow-up efforts. These outcomes were measured before and after the initial presentation of the updated pamphlet and HTN guidelines to staff and again after two months of using the pamphlet. In addition, outcomes were measured by the staff's self-reported understanding of the concepts, their use of the HTB program, and their engagement in HTN follow-up measured by the quantity of completed staff- administered follow-up surveys. Consent Procedures and Ethical Considerations Weber State University’s IRB met and determined that the project met the standard of a quality improvement or program evaluation activity and thus was exempt from needing formal IRB reviewal. Ogden Clinic decided that organizational IRB was also not required for the project. Consequently, informed consent was not needed. Surveys were administered through Qualtrics, and all responses were anonymous. In addition, responses to staff-administered follow-up surveys were handwritten on paper, kept anonymous, and locked in the practice manager’s office on-site. Staff who needed to access protected health information (PHI) did so through their secured eClinical Works charting system. No PHI was shared with the student. Data evaluation occurred on a password-protected computer. As an extra precaution to ensure MANAGING HYPERTENSION WITH HEAR THE BEAT 23 everything was done in compliance with the Health Insurance Portability and Accountability Act (HIPAA), the student performed the onboarding documentation and training necessary to obtain a badge and be cleared for an internship and clinical rotations at Ogden Clinic. The DNP project promoted health equity, decreased health disparities, and promoted social determinants of health for older adults by recommending several options for HTN follow- up. Whereas patients traditionally are asked to follow up in the clinic, many individuals— especially older adults—have limited transportation options, concerns about public safety, insufficient social support, residential segregation, poor socioeconomic conditions, and limited access to health care services (Healthy People 2030, n.d.). One way to address these barriers was to train clinical staff on various follow-up options for these older adults, including phone calls, communication through the patient portal, and BP tracking through a mobile application. Improving follow-up by staff was essential to address HTN adequately and associated heart disease, the leading cause of death in adults aged 65 and older (CDC, 2021). The project’s benefits were believed to outweigh potential risks or harms to the direct or indirect population. Instruments to Measure Intervention Effectiveness Project outcomes were measured by the staff's self-reported understanding of concepts, use of the HTB program, and engagement in HTN follow-up. Data was collected by surveys administered through Qualtrics. These surveys were adapted with permission from the Institute for Healthcare Improvement’s (IHI) Open School post-course evaluation. These were the pre- education survey (see Appendix C) and the post-education survey (also used as the pre-and post- implementation survey; see Appendix D). Results from these surveys were mainly qualitative, except for the final question asking staff to estimate a percentage of the time they recommended the HTB program. These results were used to analyze whether the staff's use of the HTB clinical tool improved and to gather their input on the project. MANAGING HYPERTENSION WITH HEAR THE BEAT 24 Because Ogden Clinic wanted to assess whether patients would benefit from the updated HTB pamphlet, the staff asked patients a brief set of questions (see Appendix E) upon follow-up. Responses to these questions were recorded by staff on paper and then locked in the practice manager's office. These surveys did not include any PHI and used descriptive statistics grouped by age greater or less than 65. These surveys also served to assess staff's follow-up efforts. MANAGING HYPERTENSION WITH HEAR THE BEAT 25 Project Implementation Project implementation began with the training of clinical staff on current HTN guidelines, updates to the HTB pamphlet, and suggested follow-up methods. Staff members were then given two months to educate any hypertensive patient on the HTB program using the pamphlet and invite them to participate. These patients were given a booklet and encouraged to perform home-based BP monitoring, track and record those BP readings, and adhere to any other ordered treatments and follow-up appointments. Regardless of whether patients agreed to participate, clinical staff members were expected to emphasize the importance of patients managing their BP and follow up with patients approximately two weeks later to evaluate their adherence to their treatment plan. The staff contacted participants two weeks after receiving the pamphlet with a brief set of six follow-up questions (Appendix E) to assess the tool’s efficacy. These questions were asked over the phone, via the patient portal, or in person in the clinic. Staff marked responses to follow-up questions on sheets of paper and placed them in a secure location in the office for analysis. Project Intervention Implementation of the project required the DNP team to develop five deliverables. These deliverables included (1) the updated HTB pamphlet, (2) the pre-implementation/education survey, (3) a PowerPoint presentation for staff training, (4) the post-implementation/education survey, and (5) the staff-administered follow-up survey for patients. The student presented these deliverables on November 19, 2021, during a staff training. The training began with completing the pre-implementation/education survey (Appendix C). Next, the PowerPoint presentation included a quick response (QR) code that staff members scanned to access and complete the survey through Qualtrics. In addition, copies of the HTB pamphlet with an inserted MANAGING HYPERTENSION WITH HEAR THE BEAT 26 copy of the patient follow-up questions was distributed by the student during the training for staff reference. Finally, the presentation concluded with time for questions, a list of references, and a QR code for the post-implementation/education survey (Appendix D) on Qualtrics. The DNP team then administered this same survey at the end of project implementation. Project Timeline Project implementation took two months and occurred in the middle of the five main project phases previously mentioned: planning, pilot, implementation, evaluation, and dissemination. The project took approximately fifteen months to complete (see Appendix F). The planning phase spanned about four months, beginning mid-June 2021 and ending in October. The pilot phase started in October and ended in November 2021, with the initiation of the implementation phase. Next, the evaluation phase took longer than expected, from late January to May 2022. Lastly, efforts to disseminate the HTB pamphlet to the other practice locations occurred from April to August 2022. MANAGING HYPERTENSION WITH HEAR THE BEAT 27 Project Evaluation Project evaluation consisted of analyzing clinical staff participants’ survey responses and patients’ answers to the staff-administered follow-up questionnaire. Survey responses from clinical staff participants were obtained by downloading the results of these surveys on Qualtrics. Questionnaire responses from patients were transferred from paper to Microsoft Excel for analysis. Data Maintenance/Security Data maintenance and security were provided for the staff and patient survey responses through various instrumentalities, including electronic password protection and secured containment. First, data obtained from clinical staff survey responses were secured through a password-protected Qualtrics account only accessible through a university-credentialed login. Because survey responses were kept anonymous, no identifiable information was obtained from staff. Next, patient responses from staff-administered questionnaires were recorded on paper and locked in the practice manager’s office. When clinical staff educated patients on the HTB pamphlet, they recorded the date the pamphlet was given, placed a sticky note on the questionnaire with the patient’s information, and secured the questionnaire in a box in the practice manager’s office. Then upon follow-up, staff retrieved the questionnaire from this box, recorded the patient’s responses, and placed it in a “completed” box locked in the practice manager’s office. No identifiable patient information was written directly on these questionnaires. Any remaining sticky notes were removed in the practice manager’s office and placed in a shredding bin before the questionnaires were removed from the clinic by the student for analysis. MANAGING HYPERTENSION WITH HEAR THE BEAT 28 Data Collection and Analysis Data collected from the clinical staff surveys on Qualtrics were exported to Excel for initial analysis and comparison. The DNP student initially analyzed data from the final five questions by converting responses to a Likert scale. For the final analysis, means and standard deviations from answers to these surveys were obtained through direct download from Qualtrics. Next, the student transcribed data from the staff-administered patient follow-up questionnaire from paper to Excel. Sums of responses of “Yes,” “No,” and “Unsure” to each question were obtained by the student and divided by the total answers for each question. For analysis of the final question, an SBP cutoff of 140 mmHg was used to delineate the number of hypertensive patients that successfully lowered their BP in their initial two weeks following the program. Findings Analysis of survey responses from clinical staff revealed an improvement in the frequency of recommending the HTB program to hypertensive patients from an average of 51.4% (standard deviation of 42.8%) to 95.5% (standard deviation of 4.5%) of the time (see Tables 1 and 2). Before education, only 33% (n=6) of staff responded “Excellent” to whether they could define national BP parameters, compared to 50% (n=6) after education and 67% (n=3) after implementation (see Table 1). After the HTB education was delivered, 83% of the clinical staff responded “Excellent” in response to their comfort level of explaining home BP tracking, compared to 50% before the staff education. In addition, the ability to identify the components of the HTB program increased from a mean of 2.00 (“Very Good”) to 1.33 (1 = “Excellent”) after education and implementation (See Table 2). MANAGING HYPERTENSION WITH HEAR THE BEAT 29 Table 1 Survey Responses of Clinical Staff Participants Response Pre-Education/ Implementation Post- Education Post- Implementation Full sample n % n % n % n % Define national BP parameters Excellent 2 33 3 50 2 67 7 47 Very Good 4 67 3 50 1 33 8 53 Components of HTB Excellent 2 33 4 67 2 67 8 53 Very Good 2 33 2 33 1 33 5 33 Good 2 33 0 0 0 0 2 13 Explain home BP tracking Excellent 3 50 5 83 2 67 10 67 Very Good 2 33 1 17 1 33 4 27 Fair 1 17 0 0 0 0 1 7 Follow-up Techniques Excellent 3 50 3 50 1 33 7 47 Very Good 1 17 2 33 1 33 4 27 Good 2 33 1 17 1 33 4 27 Frequency of recommending HTB program to hypertensive patients a 5 51.4 4 70.5 2 95.5 - - a Reflects the average percentage of responses of how often participants recommend the HTB pamphlet to patients, rated 0-100%. MANAGING HYPERTENSION WITH HEAR THE BEAT 30 Table 2 Means and Standard Deviation of Scores from Clinical Staff Participants Variable Pre-Education/ Implementation Post- Education Post- Implementation M SD M SD M SD Define national BP parameters 1.67 0.47 1.50 0.50 1.33 0.47 Components of HTB 2.00 0.82 1.33 0.47 1.33 0.47 Explain home BP tracking 1.83 1.07 1.17 0.37 1.33 0.47 Follow-up Techniques 1.83 0.90 1.67 0.75 2.00 0.82 Frequency of recommending HTB program to hypertensive patients a 51.40 42.80 56.40 44.22 95.50 4.50 Note. Numbers were assigned to responses on a Likert scale where Excellent=1, Very Good=2, Good=3, Fair=4, and Poor=5. a Reflects the average percentage of responses of how often participants recommend the HTB pamphlet to patients, rated 0-100%. Staff-administered patient questionnaires revealed that every participant indicated that the HTB booklet was helpful (see Table 3). Nearly 40% (n=16) of participants were over 65. All the participants over 65 and 93.75% of the total agreed that their knowledge and frequency of home-based BP monitoring increased due to the program. Over 80% of the participants agreed that their BP improved while using the HTB program, and 68.75% reported an SBP under 140 mmHg. All participants agreed to recommend the HTB booklet to family or friends. MANAGING HYPERTENSION WITH HEAR THE BEAT 31 Table 3 Responses from Staff-Administered Follow-up Questionnaire Baseline characteristic Yes No No Response/ Unsure n % n % n % n % Gender Female 4 25 - - - - 2 12.5 Male 10 62.5 - - - - - - Age >65 6 37.5 - - - - 1 6.3 <65 9 56.3 - - - - - - Increased knowledge of home BP monitoring - - 15 93.8 1 6.3 - - Measure BP more frequently - - 15 93.8 1 6.3 - - Improvement in BP - - 13 81.3 0 0 4 25 Booklet is helpful - - 15 100 0 0 - - Recommend booklet - - 15 100 0 0 - - Last home SBP reading < 140a - - 11 68.8 5 31.3 - - Note. Not all surveys had demographics circled for gender or age. a Reflects the number and percentage of patients reporting an SBP under 140 mmHg to this question. Strengths The HTB project improved staff knowledge of national BP parameters, patient education, and utilization of home BP monitoring. Strengths included clear positive trends in the clinical staff’s ability to define national BP parameters and identify components of the HTB program. In addition, the survey data analysis indicated an improvement in the frequency that the clinical staff recommended the HTB program to hypertensive patients, the primary goal of the DNP project. The responses from patients to the staff-administered follow-up questionnaire were MANAGING HYPERTENSION WITH HEAR THE BEAT 32 overwhelmingly positive, with unanimous affirmation that the pamphlet is helpful and would be recommended by patients to friends or family. In addition, of patients over 65, 100% (n=6) responded that their knowledge and frequency in the measurement of home-based BP monitoring increased. As a result, two other primary DNP project goals were satisfied. These results showed that the DNP team’s efforts to educate clinical staff increased their use of the HTB pamphlet and translated into more effective patient education and follow-up. Weaknesses The main weakness of the data obtained by the DNP team was the number of participants. Because Ogden Clinic – Farmington is a clinic with only three providers, the clinical staff at the clinic were unable to provide a statistically significant sample size. In addition, several staff participants that completed the first two surveys did not complete the final Qualtrics survey, resulting in compliance issues. Staff turnover contributed to this error. As a result, the sample size of patients participating in the HTB program was also not statistically significant. This could also be credited to the size of the clinic and its limited patient population due to having only three providers. MANAGING HYPERTENSION WITH HEAR THE BEAT 33 Quality Improvement Discussion The DNP project utilized new guidelines to amend the HTB clinical tool to improve the clinical staff’s management of HTN for patients, especially older adults. The project consisted of several phases to translate the most recent evidence on HTN management into practice. The project results also have implications for ongoing practice changes and future scholarship, as discussed below. Translation of Evidence into Practice The most recent evidence-based guidelines from the ISH were integrated into a clinical tool that contained outdated BP parameters and education. Because of the DNP project, the Ogden Clinic – Farmington clinical staff were empowered to incorporate the most recent evidence on HTN management into their practice. Consequently, the hypertensive patients of Ogden Clinic – Farmington now have access to an evidence-based resource capable of improving their BP. All patient participants of the updated HTB program agreed that the updated booklet was helpful and would recommend it to family and friends. In addition to being well- liked the updated HTB program helped 81.3% of the patient participants improve their BP, and 68.75% achieved an SBP under 140 mmHg in just two weeks after receiving the booklet. Implications for Practice and Future Scholarship The HTB program combined education for clinical staff on a process, updated clinical tool, and follow-up expectations for patients and staff to improve understanding and tool utility. Any time updated international or national HTN guidelines are released, clinical staff could benefit from targeted training, and patients could benefit from updated clinical tools, such as the HTB pamphlet. Project findings show that these interventions need not be lengthy to improve clinical staff’s understanding of new or current guidelines and that staff can increase their use of MANAGING HYPERTENSION WITH HEAR THE BEAT 34 clinical tools after being educated on them. In addition, the patient’s response to the updated HTB pamphlet shows that current, evidence-based clinical tools can motivate patients of all ages to become more involved in their home-based management of HTN. Sustainability Because the DNP team provided Ogden Clinic with the updated HTB pamphlet and the educational presentation for staff, these resources can be used in the future to provide a basic framework to build upon when new HTN guidelines are released. Updating these resources should require minimal organizational effort. Key players charged by the DNP student with the responsibility of championing the HTB program going forward include Ogden Clinic – Farmington’s practice manager, the clinic’s only FNP, and one of the clinic’s MAs. These individuals are in positions where they can provide exemplary leadership and motivate new and existing clinical staff members to use HTB. The practice manager has shown a willingness to request more pamphlets be printed by Ogden Clinic’s marketing department whenever necessary and did so once during the project’s Evaluation phase. Dissemination The goal of project dissemination was to implement the HTB program at two additional Ogden Clinic locations before contacting Ogden Clinic’s Family Medicine Department for approval to disseminate the new pamphlet to all Ogden Clinic locations. However, during the end of the project’s Evaluation phase and just before the Dissemination phase, several practice managers' positions changed at various Ogden Clinic locations. Upon meeting with the practice manager at the Davis Family Physicians and Grand View Ogden Clinic locations, the DNP student was told that Ogden Clinic’s quality department had recently met and decided upon several other tasks that would have to be prioritized over the HTB program. Therefore, when the DNP team receives approval to begin dissemination efforts, education in the form of a MANAGING HYPERTENSION WITH HEAR THE BEAT 35 recorded presentation will be disseminated to the clinical staff of these two clinics, and staff will be provided with the new HTB pamphlets to begin using. After this, the Family Medicine Department can be approached by the DNP team to approve the new pamphlet’s use at all Ogden Clinic locations. Conclusion A gap exists in Davis County, UT, in the screening, treatment, and follow-up of HTN. Many older adults in the county have HTN despite many accessible primary care clinics located in the county and various available community resources. It is crucial for all hypertensive individuals, especially older adults, to be screened, educated, and treated when they present to their primary care provider. Ogden Clinic – Farmington, one of the primary care clinics in the county, has a clinical tool to address the essential aspects of HTN management for patients. However, nearly all the clinical staff were unfamiliar with the tool, and it did not incorporate the most recent HTN guidelines. Therefore, the DNP team updated this clinical tool to include the BP parameters, methods of follow-up, and other suggestions from the most recent HTN guidelines from the International Society of Hypertension. After updating the HTB pamphlet, the DNP team educated the clinic’s staff on the guidelines and the updated clinical tool. The clinical staff was then given two months to utilize the HTB pamphlet with patients that presented to the clinic with an SBP over 140 mmHg. The project’s primary goals were to (a) expand staff understanding of the updated HTN guidelines, (b) increase the frequency that the staff recommended the HTB program to hypertensive patients, (c) improve hypertensive patient follow-up and home-based BP management, and (d) ultimately reduce the SBP of patients. Responses from clinical staff and MANAGING HYPERTENSION WITH HEAR THE BEAT 36 their patients revealed that all these significant goals were effectively met during project implementation. More staff stated that they understood the most recent HTN guidelines, and the new HTB program was used more frequently. In addition, upon staff’s follow-up with hypertensive patients, over 80% of the patients instructed on the HTB program agreed that their BP improved, and nearly 70% reported that their most recent BP was normotensive. Most primary care providers can improve their patient education on BP management and follow-up. Leaders in the clinic, including FNPs, can utilize tools such as the HTB pamphlet to enhance patient understanding and involvement in BP management to improve SBP and mitigate the many risks associated with HTN. This DNP project shows that HTN management interventions need not be lengthy, costly, or complex to be highly effective. Despite the simple nature of programs like HTB, the effort to be more diligent in HTN management can save the lives of patients seen in every primary care clinic worldwide every day. MANAGING HYPERTENSION WITH HEAR THE BEAT 37 References American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/DNP/DNP-Essentials American Association of Nurse Practitioners. (2019). Advocacy center: Improve access for patients who need cardiac rehabilitation services. https://www.aanp.org/advocacy/advocacy-center Beck, C. A., Beran, D. B., Biglan, K. M., Boyd, C. M., Dorsey, E. 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R., Prabhakaran, D., Ramirez, A., Schlaich, M., Stergiou, G. S., Tomaszewski, M., Wainford, R. D., Williams, B., & Schutte, A. E. (2020). 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension, 75(6), 1334–1357. https://doi.org/10.1161/HYPERTENSIONAHA.120.15026 Vetrano, D. L., Palmer, K. M., Galluzzo, L., Giampaoli, S., Marengoni, A., Bernabei, R., & Onder, G. (2018). Hypertension and frailty: A systematic review and meta-analysis. BMJ Open, 8(12), 1-8. https://doi.org/10.1136/bmjopen-2018-024406 Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., … Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension, 71(6), e13–e115. https://doi.org/10.1161/HYP.0000000000000065 MANAGING HYPERTENSION WITH HEAR THE BEAT 43 Appendix A MANAGING HYPERTENSION WITH HEAR THE BEAT 44 Appendix B MANAGING HYPERTENSION WITH HEAR THE BEAT 45 Appendix C Pre-Implementation/Education Survey Questions https://weber.co1.qualtrics.com/jfe/form/SV_6yR88hfPB4gLLPU 1 of 5 Please rate your ability to meet the following learning objectives: Define current national hypertension parameters. Excellent Very Good Good Fair Poor 2 of 5 Identify and describe the components of the Hear the Beat program. Excellent Very Good Good Fair Poor 3 of 5 Explain home-based blood pressure tracking and various methods of recording readings. Excellent Very Good Good Fair Poor 4 of 5 Explain the use of various patient follow-up techniques, including the patient portal, to engage patients in follow-up care. Excellent Very Good Good Fair Poor 5 of 5 How often do you recommend the Hear the Beat program to patients who have systolic blood pressure readings >140 mmHg? 100% 75% 50% 25% 0% Adapted with permission from the Institute for Healthcare Improvement’s Open School Post- Course Survey found at http://www.ihi.org/education/IHIOpenSchool/Pages/default.aspx. MANAGING HYPERTENSION WITH HEAR THE BEAT 46 Appendix D Post-Implementation/Education Survey Questions https://weber.co1.qualtrics.com/jfe/form/SV_bBNHkAPS7BQT2CO 1 of 10 What did you like about this training? 2 of 10 How can we improve this training for future learners? (e.g., What’s missing? What could be clearer?) 3 of 10 Please share a brief example of how you will apply the skills you learned or what you will do differently because of this training. 4 of 10 Was this subject matter presented objectively, with fair balance, and free of commercial bias? Yes No Unsure 5 of 10 If you answered “no" or "unsure" to the previous question, please elaborate: 6 of 10 After completing this training, please rate your ability to meet the following learning objectives: Define current national hypertension parameters. MANAGING HYPERTENSION WITH HEAR THE BEAT 47 Excellent Very Good Good Fair Poor 7 of 10 Identify and describe the components of the Hear the Beat program. Excellent Very Good Good Fair Poor 8 of 10 Explain home-based blood pressure tracking and various methods of recording readings. Excellent Very Good Good Fair Poor 9 of 10 Explain the use of various patient follow-up techniques, including the patient portal, to engage patients in follow-up care. Excellent Very Good Good Fair Poor 10 of 10 How often do you recommend the Hear the Beat program to patients who have systolic blood pressure readings >140 mmHg? 100% 75% 50% 25% 0% Adapted with permission from the Institute for Healthcare Improvement’s Open School Post- Course Survey found at http://www.ihi.org/education/IHIOpenSchool/Pages/default.aspx MANAGING HYPERTENSION WITH HEAR THE BEAT 48 Appendix E Follow-up Questions for Patients Date Given Booklet (Initial Visit): Today’s Date: Gender: Is Patient >65:Y / N HEAR THE BEAT 2-WEEK FOLLOW-UP SURVEY Check all that apply as you follow up with patients (over the phone, patient portal, or in clinic): Since receiving the Blood Pressure & Education booklet: 1 of 6 Has your knowledge of home-based blood pressure monitoring increased? Yes No Unsure If yes, how? 2 of 6 Do you measure your blood pressure more frequently using your own home-based blood pressure monitor? Yes No Unsure 3 of 6 Have you seen any improvement in your blood pressure readings since you received the booklet (decrease in the top number, known as the “systolic” blood pressure)? Yes No Unsure 4 of 6 Would you say that the booklet is helpful? Yes No Unsure 5 of 6 Would you recommend the booklet to family or friends? Yes No Unsure 6 of 6 What was your last blood pressure reading: / Have Been Recording, But Don’t Know Haven’t Been Recording MANAGING HYPERTENSION WITH HEAR THE BEAT 49 Appendix F MANAGING HYPERTENSION WITH HEAR THE BEAT 50 Appendix G Table 1 Survey Responses of Clinical Staff Participants Response Pre-Education/ Implementation Post- Education Post- Implementation Full sample n % n % n % n % Define national BP parameters Excellent 2 33 3 50 2 67 7 47 Very Good 4 67 3 50 1 33 8 53 Components of HTB Excellent 2 33 4 67 2 67 8 53 Very Good 2 33 2 33 1 33 5 33 Good 2 33 0 0 0 0 2 13 Explain home BP tracking Excellent 3 50 5 83 2 67 10 67 Very Good 2 33 1 17 1 33 4 27 Fair 1 17 0 0 0 0 1 7 Follow-up Techniques Excellent 3 50 3 50 1 33 7 47 Very Good 1 17 2 33 1 33 4 27 Good 2 33 1 17 1 33 4 27 Frequency of recommending HTB program to hypertensive patients a 5 51.4 4 70.5 2 95.5 - - a Reflects the average percentage of responses of how often participants recommend the HTB pamphlet to patients, rated 0-100%. MANAGING HYPERTENSION WITH HEAR THE BEAT 51 Appendix H Table 2 Means and Standard Deviation of Scores from Clinical Staff Participants Variable Pre-Education/ Implementation Post- Education Post- Implementation M SD M SD M SD Define national BP parameters 1.67 0.47 1.50 0.50 1.33 0.47 Components of HTB 2.00 0.82 1.33 0.47 1.33 0.47 Explain home BP tracking 1.83 1.07 1.17 0.37 1.33 0.47 Follow-up Techniques 1.83 0.90 1.67 0.75 2.00 0.82 Frequency of recommending HTB program to hypertensive patients a 51.40 42.80 56.40 44.22 95.50 4.50 Note. Numbers were assigned to responses on a Likert scale where Excellent=1, Very Good=2, Good=3, Fair=4, and Poor=5. a Reflects the average percentage of responses of how often participants recommend the HTB pamphlet to patients, rated 0-100%. MANAGING HYPERTENSION WITH HEAR THE BEAT 52 Appendix I Table 3 Responses from Staff-Administered Follow-up Questionnaire Baseline characteristic Yes No No Response/ Unsure n % n % n % n % Gender Female 4 25 - - - - 2 12.5 Male 10 62.5 - - - - - - Age >65 6 37.5 - - - - 1 6.3 <65 9 56.3 - - - - - - Increased knowledge of home BP monitoring - - 15 93.8 1 6.3 - - Measure BP more frequently - - 15 93.8 1 6.3 - - Improvement in BP - - 13 81.3 0 0 4 25 Booklet is helpful - - 15 100 0 0 - - Recommend booklet - - 15 100 0 0 - - Last home SBP reading < 140a - - 11 68.8 5 31.3 - - Note. Not all surveys had demographics circled for gender or age. a Reflects the number and percentage of patients reporting an SBP under 140 mmHg to this question.