Digital Repository Doctoral Projects Fall 2022 Blood Pressure Self-Monitoring Implementation Guide Jacob Ewell Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Ewell, J. (2022) Blood pressure self-monitoring implementation guide 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. BLOOD PRESSURE SELF-MONITORING 1 Blood Pressure Self-Monitoring Implementation Guide by Jacob Ewell 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 _______________________________ ______________________________ Jacob Ewell, FNP-DNP-S, BSN, RN Date _______________________________ _____________________________ Angela Page, DNP, APRN, PPNP-BC Date Faculty Project Lead _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Note: The program director must submit this form and paper. Angela Page December 16, 2022 December 16, 2022 Jacob Ewell December 16, 2022 BLOOD PRESSURE SELF-MONITORING 2 Table of Contents Abstract ........................................................................................................................................... 4 Blood Pressure Self-Monitoring Implementation Guide ................................................................ 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 Synthesis of Literature ................................................................................................................ 8 Risk Factors ............................................................................................................................. 8 Consequences .......................................................................................................................... 9 Treatment ................................................................................................................................. 9 Barriers to Treatment ............................................................................................................. 12 Solutions ................................................................................................................................ 14 Framework ................................................................................................................................ 17 Discussion ................................................................................................................................. 18 Implications for Practice ........................................................................................................... 19 Project Plan ................................................................................................................................... 19 Project Design ........................................................................................................................... 19 Needs Assessment/Gap Analysis of Project Site and Population ............................................. 20 Cost Analysis and Sustainability of Project .............................................................................. 21 Table 1 ....................................................................................................................................... 21 Project Outcomes ...................................................................................................................... 22 Consent Procedures and Ethical Considerations ....................................................................... 23 Instrument(s) to Measure Intervention Effectiveness ............................................................... 23 Project Implementation ................................................................................................................. 23 Interventions .............................................................................................................................. 24 Project Timeline ........................................................................................................................ 25 Project Evaluation ......................................................................................................................... 25 Data Maintenance and Security................................................................................................. 26 Data Collection and Analysis .................................................................................................... 26 Table 2 ....................................................................................................................................... 27 Table 3 ....................................................................................................................................... 28 BLOOD PRESSURE SELF-MONITORING 3 Findings ..................................................................................................................................... 28 Strengths .................................................................................................................................... 29 Weakness ................................................................................................................................... 29 Discussion ..................................................................................................................................... 29 Translation of Evidence Into Practice ....................................................................................... 29 Implications for Practice and Future Scholarship ..................................................................... 30 Sustainability ......................................................................................................................... 31 Dissemination ........................................................................................................................ 31 Conclusion .................................................................................................................................... 32 References ..................................................................................................................................... 33 Appendix A ................................................................................................................................... 39 Appendix B ................................................................................................................................... 40 Appendix C ................................................................................................................................... 41 Appendix D ................................................................................................................................... 42 Appendix E ................................................................................................................................... 43 Appendix F.................................................................................................................................... 44 Appendix G ................................................................................................................................... 46 Appendix H ................................................................................................................................... 47 BLOOD PRESSURE SELF-MONITORING 4 Abstract Purpose: Blood pressure self-monitoring (SMBP) can improve hypertension (HTN) and adherence to HTN treatments. Comagine Health, a nonprofit healthcare consulting firm, works with Utah clinics and providers to improve the delivery of healthcare services to patients. Comagine needed to update HTN resources on their website specific to SMBP and clinic workflows for HTN management. This DNP project aimed to develop a web-based guide to educate patients and support clinics as they provide HTN management with an emphasis on SMBP. Methodology: A pre-survey conducted by Comagine Health indicated a need for additional HTN resources to improve workflows and resources related to SMBP. The author developed an up-to-date, evidence-based website resource for HTN and SMPB management. The web-based guide was presented to clinics and partners of Comagine, who provided quantitative and qualitative data through a Likert scale and free-text box options to evaluate guide effectiveness. An additional survey completed by Comagine Health determined if the guide was accepted or rejected. Results: The results indicated that Comagine Health accepted the guide. The feedback from providers, clinics, and the Patient Family Advisory Council (PFAC) demonstrated that the project effectively delivered evidence-based SMBP and HTN management resources. Implications for practice: The results indicated that an SMBP guide can benefit and improve HTN management workflow and provide clinics with the evidence-based and up-to-date resources they need to implement an SMBP program in their clinic. Key Words: hypertension, blood pressure, self-measured blood pressure, self-monitoring, patient education, provider education, workflow. BLOOD PRESSURE SELF-MONITORING 5 Blood Pressure Self-Monitoring Implementation Guide Hypertension (HTN) or high blood pressure is a “silent killer” (American Heart Association [AHA], 2021). In the United States, roughly 45% of individuals suffer from HTN, and 24% of hypertensive patients adequately manage their HTN (Centers for Disease Control and Prevention [CDC], 2020). Uncontrolled HTN can lead to major diseases, such as stroke, myocardial infarction, peripheral artery disease, heart failure, vision loss, and can worsen diabetes (AHA, 2016). More than 80% of patients with HTN see a provider an average of four times a year, yet these clinicians are hesitant to begin antihypertensive treatment or increase treatment intensity (Margolis et al., 2020). A team-based approach focused on treating HTN through blood pressure self-monitoring effectively decreases HTN (McManus et al., 2018). The primary purpose of this project is to plan, implement, and evaluate an evidence-based blood pressure self-monitoring guide to improve HTN management for patients and outpatient clinic teams associated with Comagine Health. Background and Problem Statement Public health organizations and clinics recognize the effectiveness of self-monitoring blood pressure programs to improve HTN management and long-term treatment goals (Roy et al., 2021). Comagine Health (2019) is a neutral nonprofit organization that works with federal, state, and other local government agencies to improve and redesign healthcare systems for better healthcare delivery. Numerous providers, clinics, and public health organizations have contacted Comagine Health requesting more information, education, resources, and tools to create and implement blood pressure self-monitoring programs. As a result of these inquiries, Comagine Health began researching the possibility of creating a self-monitoring implementation guide for community partners, providers, and clinics (Comagine Health, 2019). This project aims to BLOOD PRESSURE SELF-MONITORING 6 improve the accessibility of self-monitoring resources to patients, providers, and public health organizations to reduce the long-term chronic effects of HTN (David Cook & Rebecca Wilson, personal communication, May 17, 2021). Diversity of Population and Project Site The project population consists of providers, clinics, and patients throughout Utah. The final product will be available to any who wishes to access the Comagine Health website. The implementation guide allows providers who work in private and public healthcare clinics to have equal access to this resource, regardless of whether they bill through Medicare or Medicaid. Open access to this resource provides HTN management protocols and workflows for various patients and populations, such as those of lower socioeconomic status, immigrants, or non-English speakers (D. Cook & R. Wilson, personal communication, May 17, 2021). Significance for Practice Reflective of Role-Specific Leadership Doctor of Nursing Practice (DNP)/Family Nurse Practitioner (FNP) leaders are critical in implementing blood pressure self-monitoring to improve patient health outcomes. By gathering resources on evidence-based practice, the DNP/FNP leader can effectively collaborate with HTN experts to develop an effective HTN self-monitoring implementation guide (Andrusin et al., 2018). Integrating this guide into clinic workflows can improve patient outcomes, advance healthcare models, and provide exemplary care to all patients regardless of race or demographics. This project will fulfill the American Association of Colleges of Nursing’s (AACN) DNP competency seven, which focuses on advancing clinical prevention, population health, and overall national health improvement (American Association of Colleges of Nursing [AACN], 2006). BLOOD PRESSURE SELF-MONITORING 7 Literature Review and Framework This literature review compares evidence and best-practice methods from various guidelines and addresses how blood pressure self-monitoring improves hypertensive treatment. The following themes emerged to create and implement an effective blood pressure self-monitoring toolkit for Comagine Health: (a) the need for improved education, diagnosis, treatment, and patient adherence to HTN management; (b) effective HTN treatment involves complex interventions, including lifestyle changes, pharmacological intervention, and consistent patient to provider communication; and (c) self-monitoring blood pressure is an effective way to improve HTN treatment adherence when combined with other treatment strategies. The framework used to guide this project is the plan-do-study-act (PDSA) model (Institute for Healthcare Improvement [IHI], 2021). Research for this project was gathered from three HTN guidelines: 1) The Global Hypertension Practice Guide, written by Unger et al. and published by the American Heart Association (AHA) (2020); 2) a guideline published by the American College of Cardiology (ACC) and the AHA, written by Whelton et al. (2018); and 3) a guideline approved by the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH), written by Williams et al. (2018). Additional research was gathered from the AHA, the ESC, and the Centers for Disease Control and Prevention (CDC). Search Methods Databases used included PubMed, One Search, Google Scholar, Science Direct, and other scholarly websites ending in .org, .edu, and .gov. These searches provided direction to find relevant scholarly journal articles, HTN guidelines, existing blood pressure toolkits, and evidence-based studies. BLOOD PRESSURE SELF-MONITORING 8 Search terms used included hypertension, adherence, blood pressure, blood pressure self-monitoring, telehealth blood pressure monitoring, and guidelines for HTN treatment. Database search exclusion criteria included journal articles older than 15 years. Synthesis of Literature HTN causes severe health complications, including death, stroke, kidney disease, heart failure, myocardial infarction, and extensive damage to the body’s vasculature (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). As defined in the ACC guideline for HTN, two blood pressure readings obtained on separate occasions are used to diagnose HTN or prehypertension (Whelton et al., 2018). An acceptable adult blood pressure is under 120/80 mm Hg (systolic/diastolic). Elevated blood pressure indicates that the patient is at risk of HTN and is between 120 and 129 systolic. Stage 1 HTN is between 130 and 139 systolic, and Stage 2 is any blood pressure measured to be greater than 140 mmHg systolic or 90 mmHg diastolic (Whelton et al., 2018). “The International Society of Hypertension Global Hypertension Practice Guidelines” defines HTN using these metrics (Unger et al., 2020). Risk Factors Modifiable and non-modifiable risk factors influence the possibility of developing HTN (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). Non-modifiable risk factors include elements that an individual cannot control, such as genetics and family history of HTN, advanced age, socioeconomic background, and ethnicity (McCance & Huether, 2019). Minority and uninsured groups are more likely to have untreated HTN (Hanlin et al., 2018). For example, the Black population in the United States is at higher risk as Blacks have a prevalence of HTN at 42.1% (Wall et al., 2014). In contrast, whites in the United States have a prevalence rate of HTN at 27.8 %, Asians at 25.0%, and Hispanics at 27.8% (CDC, 2017). While non-modifiable risk BLOOD PRESSURE SELF-MONITORING 9 factors may not be alterable, decreasing modifiable risk factors can aid individuals in improving their health to avoid hypertensive complications (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). Treatment for HTN often focuses on lifestyle changes and adjustments to modifiable risk factors (Marcello et al., 2018; Unger et al., 2020). Modifiable risks for HTN include being overweight or obese, smoking, diabetes, hyperlipidemia, lack of physical activity, and unhealthy diets that include excessive alcohol consumption or excessive salt intake (Marcello et al., 2018; Whelton et al., 2018). Obesity is directly linked to increased blood pressure (Marcello et al., 2018). In addition, diabetes is prevalent in 71% of hypertensive patients and contributes to HTN (Whelton et al., 2018). Consequences HTN is the leading cause of mortality and morbidity worldwide, and individuals with untreated HTN can be subject to multiple chronic diseases, such as chronic renal insufficiency, myocardial infarction, and stroke (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). More than 50% of HTN patients have additional cardiovascular risk factors, and HTN has been found to predate heart failure in three out of four patients (Unger et al., 2020). Every decrease in blood pressure by ten mmHg will reduce heart failure risk by 28%, stroke by 27%, coronary artery disease by 17 %, and all causes of death by 13% (Qamar & Braunwald, 2018). Treatment Treatment of HTN includes pharmacological interventions and nonpharmacological interventions. Care adjustments such as modifying the patient’s diet, improving exercise habits, smoking cessation, and other lifestyle changes are recommended by providers (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). Repeat screening of blood pressure and BLOOD PRESSURE SELF-MONITORING 10 treatment compliance is required to ensure treatment success (Burnier & Egan, 2018). Patient self-monitoring blood pressure is an effective screening and treatment tool for patients and providers to improve treatment adherence through patient self-awareness and provider follow-up (Whelton et al., 2018). Nonpharmacological Treatments. Nonpharmacological therapies are the first line of care in pre-hypertensive and hypertensive patients (Unger et al., 2020; Whelton et al., 2018). The most important intervention to reduce blood pressure is weight loss. According to the guideline published by the ESC (2018), hypertensive mortality rates were lowest at a Body Mass Index (BMI) of 22.5-25. Weight loss has been shown to improve the efficacy of antihypertensive medications (Williams et al., 2018). The guideline approved by the ACC and AHA (2018) also states that each kilogram of weight reduction is generally correlated to 1 mm Hg of reduced blood pressure. Weight loss can be achieved through exercise, such as aerobic exercises 90-150 minutes per week, dynamic resistance 90-150 minutes per week, or isometric exercises. Exercise as specified may result in a 4-8 mmHg reduction in blood pressure in hypertensive patients even when no weight loss is achieved (Whelton et al., 2018). Diet is also essential in reducing blood pressure (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). Multiple guidelines recommend the Dietary Approaches to Stop Hypertension or DASH diet as an effective diet high in vegetables, fruits, whole grains, low-fat dairy products, and a reduced saturated and total fat intake (Whelton et al., 2018; Williams et al., 2018). The DASH diet may decrease HTN by up to 11 mmHg (Whelton et al., 2018). Other critical dietary modifications include reducing sodium intake to less than 1500 mg per day, ensuring potassium intake between 3500-5000 mg per day, and reducing alcohol intake to less than one drink for women and two drinks for men per day (Whelton et al., 2018). BLOOD PRESSURE SELF-MONITORING 11 Pharmacological Treatments. While lifestyle changes can improve hypertensive management, most patients with HTN will need medication to manage their HTN (Williams et al., 2018). However, recent data suggests that fewer than 50% of adults with HTN receive hypertensive medication (Unger et al., 2020). The initiation of pharmacological treatment is recommended in patients who have a history of cardiovascular disease (CVD) and have systolic blood pressure greater than 130/ 80 (systolic/diastolic) mm Hg or patients with no CVD and blood pressure greater than 140/90 (systolic/diastolic). The initiation of non-pharmacologic and pharmacologic agents should be used to treat blood pressure, with outpatient visits scheduled every 3 to 6 months to assess treatment progress (Whelton et al., 2018). Primary pharmacological agents consist of thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBS), and calcium channel blockers. Secondary treatment options include beta blockers, loop and potassium-sparing diuretics, direct renin inhibitors, alpha-1 blockers, alpha-2 agonists, and direct vasodilators. Choices and combinations of medications will differ based on patient allergies, reaction to the drug, ethnicity, and severity of HTN (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). The ACC AHA guidelines by Whelton et al. (2018) and Unger et al. (2020) can be used as a reference when treating and prescribing medications to hypertensive patients in the United States. These guidelines are intended for providers’ and patients’ use as the official policy of the ACC and AHA (2018; 2020). The AHA also has a self-monitoring blood pressure toolkit available online to support providers and patients (AHA, 2021). The effectiveness of these tools depends upon both the provider and patient compliance to the treatment guidelines and toolkit recommendations. The guideline and toolkit are updated with the most up-to-date research every BLOOD PRESSURE SELF-MONITORING 12 six years to ensure the most effective evidence-based practice (AHA, 2021; Unger et al., 2020; Whelton et al., 2018). Barriers to Treatment Many barriers can prevent patients from effectively treating their HTN (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). In the United States, an estimated 13 million people are unaware that they have HTN (Wall et al., 2014). After patients are diagnosed, adherence to hypertensive treatments and medications is less than 50% in all hypertensive patients (Burnier & Egan, 2018). Self-monitoring has been shown to improve adherence to hypertensive treatment; however, patients often cannot independently monitor and manage their blood pressure from home (Meredith et al., 2020). Providers cannot adjust hypertensive therapies without sufficient blood pressure data, and patients remain unaware that their blood pressure is a problem. Many patients do not self-monitor because they do not have access to self-monitoring equipment, which may be because of cost, inadequate technology, or inadequate training and education (Roy et al., 2021). The disparities in uncontrolled HTN may also result from low socioeconomic backgrounds, minorities, and those with low health literacy levels (Meredith et al., 2020). Providers are also responsible for some of the barriers to hypertensive treatment. Of the 13 million in the United States who are unaware of their HTN, 82.5% had a regularly scheduled appointment to see a provider but remained untreated or unaware of their HTN (Wall et al., 2014). Atreja et al. (2005) observe that providers often do not provide sufficient education and patient training when patients are diagnosed because HTN education plans can be lengthy and time-consuming. In addition, providers often lack an understanding of the available resources that can be quickly and easily implemented (Atreja et al., 2005). As a result of infrequent office BLOOD PRESSURE SELF-MONITORING 13 visits, providers may be hesitant to increase hypertensive medication therapy based on a single office visit; this reduced screening and monitoring impede preventative hypertensive treatment (Margolis et al., 2020). Non-adherence. Adherence is defined as compliance to treatment goals and taking prescribed medications as directed per medical advice (Unger et al., 2020; Burnier & Egan, 2018). In HTN, adherence to treatment includes taking medication, monitoring one's blood pressure, and making lifestyle changes recommended by the patient's provider. Statistics show that HTN patients are less than 50% compliant with pharmacotherapy; this figure indicates that only 20-50% of patients being treated receive adequate treatment to prevent adverse effects of HTN (Burnier & Egan, 2018). Poor adherence to hypertensive treatment correlates directly with increased blood pressure (Unger et al., 2020). Some progress has been made in understanding the barriers behind non-compliance. In the United States, in the last few years, adherence has risen significantly to 70% in some cases (Burnier & Egan, 2018). Various factors contribute to non-adherence, including patients discontinuing medications because of side effects, complex dosing schedules, economic disadvantages contributing to the inability to afford medications, and health literacy (Vrijens et al., 2017; Williams et al., 2018). Despite efforts to improve adherence, some factors have little to no effect on patient outcomes. For example, Burnier and Egan (2018) illustrate that whether a patient has private or public insurance has little impact on patient adherence to treatment regimens. Healthcare providers must ensure treatment compliance while recognizing that adherence depends heavily on the patient. Cost. The cost of non-adherence or sub-adherence to hypertensive medication and treatment is high (Burnier & Egan, 2018; Mohanan et al., 2019; Williams et al., 2018). In the BLOOD PRESSURE SELF-MONITORING 14 United States, an estimated 10% of healthcare costs result from non-adherence or sub-adherence to hypertensive treatment (Burnier & Egan, 2018). The ESC has identified that early identification of non-adherence to treatment regimens can reduce healthcare costs (Williams et al., 2018). The average cost of preventative HTN treatment is around $22 a month, whereas the average cost per month of treatment for congestive heart failure and stroke care can range from $300 to $1,000 a month (Gheorghe et al., 2018). Uncontrolled HTN can result in stroke, heart failure, myocardial infarctions, and other complications, which cause expensive hospitalizations with an average cost of $21,094 per patient (Wang et al., 2010). Blood pressure self-monitoring can reduce healthcare costs compared to standard primary care visits for blood pressure monitoring (Monahan et al., 2019). Solutions The most effective methods for properly managing HTN involve complex interventions. As evidenced in the three guidelines, each of the following solutions will be most successful when combined with other solutions (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). Patient Education and Adherence. Patient education is fundamental to improving adherence to hypertensive treatment and management (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). Providers must present education at a health literacy level that the patient can understand (Meredith et al., 2020). Education focused specifically on the patient, the patient's personal beliefs and ideas concerning treatment, and the patient's pathological understanding can improve treatment compliance (Al-Noumani et al., 2019). Provider Education and Participation. Better education and resources for providers can also improve hypertensive treatment for patients. Because providers are busy, they need BLOOD PRESSURE SELF-MONITORING 15 resources that can be quickly and easily implemented to educate hypertensive patients successfully (Atreja et al., 2005). One example of this is the mnemonic SIMPLE (simplifying regimen characteristics, imparting knowledge, modifying beliefs, patient communication, leaving the bias, and evaluating adherence) as referenced in Al-Noumani et al. (2019) and initially implemented by Atreja et al. (2005). SIMPLE is one example of a quick and easy program to execute; as providers adjust care to meet patient needs in terms they understand, it will improve provider-to-patient education and patient adherence to treatment plans (Atreja et al., 2005). Sany et al. (2020) suggest that providers be given additional training that focuses on counseling and educating patients to improve patient adherence to medication, treatment, and participation in hypertensive care. Empowerment-based counseling can encourage patients to take responsibility for their HTN management (Unger et al., 2020). Meredith et al. (2020) also suggest that educational programs focusing on using multiple disciplines and a team-based approach with various healthcare team members providing instruction may improve overall patient education. These multidisciplinary teams can focus patient education on the patient's needs and share culturally adapted education. Involving other healthcare team members, such as pharmacists, can also help to improve monitoring for adherence (Unger et al., 2020). Additionally, group education programs can provide added support to patients with HTN that may not have access to resources or social support. These groups can improve education for treating HTN and serve many patients simultaneously, which may decrease costs for healthcare organizations (Meredith et al., 2020). Provider Treatment Plans. Effective treatment plans are fundamental to improving HTN outcomes (Whelton et al., 2018; Williams et al., 2018). When adapting and creating treatment plans for HTN, providers must be mindful of patient barriers that may put patients at BLOOD PRESSURE SELF-MONITORING 16 risk for decreased care, such as reduced social support and barriers to healthier lifestyle options such as healthy food and exercise, health literacy, medication cost, and other healthcare costs (Whelton et al., 2018). Providers should evaluate medication treatments for undesired side effects, complex medication schedules, and other patient medication concerns (Burnier & Egian, 2019; Williams et al., 2018). Adherence can also be improved by simplifying patient treatments by using single-pill drug combinations, longer-acting drugs taken once per day, and making drugs more easily accessible and affordable (Unger et al., 2020; Burnier & Egian, 2019). Self-monitoring Blood Pressure. In connection with treatment from a provider, self-monitoring programs are needed to improve the management of HTN (Sheppard et al., 2019). At-home self-monitoring blood pressure measurements have been shown to improve blood pressure management and control compared to standard inpatient monitoring (McManus et al., 2018). When trained successfully, patients can take their blood pressure and provide data to a clinic for improved titration of hypertensive treatment (Roy et al., 2021). Self-monitoring can help screen patients for compliance to treatment and focus on the titration of hypertensive treatments when the patient is not in the provider's office (Burnier & Egian, 2019). The ESC guideline (2018) states that at-home monitoring can also provide more substantial prognostic evidence since blood pressure is measured in real-life settings (Williams et al., 2018). The AHA and ACC guidelines (2020; 2018) agree that with the means to self-monitor, patients can avoid extended periods without adequate screening and treatment and consistently get the care they need (Unger et al., 2020; Whelton et al., 2018). Hanlin et al. (2018) used a community-based clinic to determine the effectiveness of implementing the Measure accurately, Act rapidly, and Partner with patients (MAP) evidence-based protocol to improve HTN in underserved populations. The study had 714 participants with BLOOD PRESSURE SELF-MONITORING 17 elevated blood pressure and used education, blood pressure self-monitoring, and medication adjustments to decrease HTN in the disadvantaged population. They found that participants had a decrease in blood pressure, resulting in improved HTN control from the baseline assessment. At the baseline assessment, 62.5 % of Whites and 57.6% of Blacks had controlled HTN, and after implementing MAP, 96.6% of Whites and 88.2% of Blacks had controlled blood pressure. The results indicate that implementing the MAP protocol in underserved population clinics improves HTN control and management. The study further demonstrates that tracking blood pressure measurements in the electronic health record (EHR) can help determine the effectiveness of blood pressure treatment and plan future interventions (Hanlin et al., 2018). Technology. Computer or app-based teaching programs may be beneficial in helping to educate patients and their families on HTN when paired with other educational resources and personal education provided by a provider to discuss treatment and clarify patient questions (Langford et al., 2019; Williams et al., 2018; Yeung et al., 2017). One example is the AHA Blood Pressure Toolkit, which includes eLearning micromodules with online videos and interactive presentations patients can use to learn about HTN and how to treat it (AHA, 2021). Providing QR codes linked to educational resources about treatment and medication can be helpful for patients to access information easily (Yeung et al., 2017). In addition to educational resources, treatment apps have proven to provide patient support with medication adherence by providing reminders and to help ensure patients receive the treatment they need through hypertensive data provided by their smart devices (Contreras et al., 2018; Williams et al., 2018). Framework The plan-do-study-act (PDSA) model from the Institute for Healthcare Improvement (IHI) will be used as a framework for creating a blood pressure self-monitoring implementation BLOOD PRESSURE SELF-MONITORING 18 guideline (2021). The PDSA model is a quality improvement model focused on developing a system to improve healthcare quality. It consists of four steps: plan, do, study, and act. The first step is to create a plan. This step focuses on setting goals for improvement, planning how changes will be made, identifying for whom they will be made, and articulating how they will be accomplished. The second step entails carrying out the change, observing and gathering data, and making observations. The third step is to analyze data and compare it to predictions. The last step is to act or roll out the change and then repeat the cycle until the change is ready to be implemented fully (Institute for Healthcare Improvement [IHI], 2021). The PDSA Model works well with this project because the implementation guide will serve various healthcare groups and organizations with various needs. As the project is framed and created for use, it will continue to be passed through this cycle to ensure ingenuity and continued use of the implementation guideline. This project will require collecting data from various experts and users, and many ideas will need to be adjusted. The PDSA cycle also allows the development process for this project to be very fluid, providing a system for continual improvement throughout the project’s duration. Discussion Evidence from the three guidelines discussed supports the effectiveness of a blood pressure self-monitoring implementation guideline and demonstrates the need to improve blood pressure self-monitoring (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). Studies show that these changes in lower-income and underprivileged socioeconomic groups and higher economic groups can significantly improve patient outcomes (Hanlin et al., 2018). Some of the studies focused on data and information from other countries, which may not accurately represent the outcomes within the population to be served by this project (Hanlin et al., 2018; BLOOD PRESSURE SELF-MONITORING 19 Williams et al., 2018). Because blood pressure treatment has various treatment options, it is difficult to identify one common theme to improve blood pressure; instead, various complex suggestions must be explored to determine effective treatment and care (Unger et al., 2020; Whelton et al., 2018; Williams et al., 2018). Implications for Practice Blood pressure self-monitoring is focused on prevention and quality improvement within healthcare. Self-monitoring empowers patients and providers to adjust medications and therapies accurately to reduce chronic healthcare complications and outcomes (Burnier & Egan, 2018). The increased screening will improve the quality of care and patient safety. Self-monitoring will empower patients to be more involved in their treatment and inspire improved interactions between patients and providers, thus creating a more unified and patient-safe healthcare system (Unger et al., 2020). The core values of the FNP/DNP role, including implementation of scientific best practice, promotion of quality improvement, use of technology, and improved patient outcomes, work in tandem with the development of the guide to advance the prevention of HTN in the United States (AACN, 2006). Project Plan The project plan consisted of creating a blood pressure self-monitoring implementation guide to be used by Comagine Health and its corresponding clinics and providers. The guide includes a functioning clinic workflow model and educational materials for providers and patients throughout Utah. Project Design This quality improvement project was designed to enhance the ease and delivery of a self-monitoring blood pressure system in clinics for providers and patients. The design included BLOOD PRESSURE SELF-MONITORING 20 evaluating current workflows, gathering resources, and suggesting process improvements. Areas for improvement were identified by reviewing current workflows and a previously existing self-monitoring blood pressure toolkit. Additional resources were gathered and evaluated to create a new guide with more effective educational material for providers and patients. The completed guide offers suggestions for workflow improvement, patient and provider communication, and self-monitoring methods. Needs Assessment/Gap Analysis of Project Site and Population This project addressed the gap that Comagine Health did not have a Blood Pressure Self-Monitoring Implementation Guide available for their partner clinics. The gap was identified by a presurvey sent to Utah clinics by Comagine Health to evaluate blood pressure treatment needs. The results indicated that Utah clinics have a great need for self-monitoring blood pressure resources. According to the survey, the top five areas where clinics needed additional help were a self-monitoring blood pressure program, team-based HTN workflow, HTN education resources, quality improvement projects, and staff training on HTN. The guide produced by this project aimed to improve equitable delivery of HTN services for lower-income and diverse populations by improving resource availability for any provider or health organization in Utah, including lower-income clinics and clinics with fewer resources. Further goals included providing educational materials in Spanish to improve gaps in education and communication across ethnic barriers (Carey et al., 2018). Advancing to a team-based healthcare approach allowed better focus on effective teaching, medications, social barriers, healthy eating, and blood pressure monitoring (Meredith et al., 2020). This project addressed a direct population of clinics and healthcare organizations throughout Utah, with an indirect population including the patients that will benefit from BLOOD PRESSURE SELF-MONITORING 21 improved blood pressure management. Since Comagine Health works with privately funded healthcare groups, government healthcare groups, individual providers, and healthcare groups financed by Medicare and Medicaid throughout Utah, the demographics of the patient population roughly reflect the demographics of the state (Comagine Health, 2019). The Utah Department of Health estimates that one in five Utah residents belongs to an ethnic or racial minority group, including Asian, Hispanic, American Indian, Black, and Pacific Islander (2021). Major stakeholders for this project included David Cook, director of Comagine Health; Rebecca Wilson, quality improvement coordinator; and members of the Million Hearts Campaign. Cost Analysis and Sustainability of Project The cost of this project was supported by Comagine Health, who will distribute the guide and keep it up to date for sustainability purposes. Rebecca Wilson and Dave Cook will maintain the guide and ensure it remains up to date and accessible to patients, providers, and clinics. No other direct funds were required for this project. Individual clinics may have their own costs, such as obtaining blood pressure cuffs for patients to use, costing around $50 each. The new guide addresses suggestions for meeting these costs, noting that clinics may obtain cuffs through insurance or personal cost to the patient. Clinics may also opt to provide blood pressure cuffs to patients by implementing a program to loan blood pressure cuffs, which could be funded by grants or donations (CDC, 2021). Table 1 Budget for the Creation of Comagine Health’s Self-Monitoring Implementation Guide Expenses/Tasks Expected Cost Expected Hours Meeting with expert providers $0.00 4 BLOOD PRESSURE SELF-MONITORING 22 Meeting with Patient Advisory Council $0.00 2 Input from other creators of implementation guides $0.00 10 Training attended for Million Hearts, AHA, and other organizations $0.00 4 Meeting with clinics to evaluate current workflows and assess needs for the guide $0.00 2 Gathering informational materials to be used in the guide $0.00 20+ Compiling the guide $0.00 20+ Donated blood pressure cuffs $2,500.00 (Each cuff costs about $50; this is the estimated cost if 50 were donated) 1 Website design for the implementation guide $0.00 (This will not create a new cost for Comagine because they already have a team that updates and maintains their website.) 4 Project Outcomes The project outcomes will be evaluated by measurement of the following goals: • The short-term goal is that blood pressure self-monitoring management and educational resources will be more accessible and available to clinics throughout Utah. • Accessibility and satisfaction were measured by a survey sent to clinics and providers in August of 2022. • The long-term goal is for providers and clinics in Utah to implement the guide to improve blood pressure management and patient education, thus improving patient blood pressure management and overall health. BLOOD PRESSURE SELF-MONITORING 23 Consent Procedures and Ethical Considerations Verbal and written consent to develop the guide and publish it on Comagine’s website was provided by Rebecca Wilson at Comagine Health. The Weber State Institutional Review Board (IRB) approved the project for quality improvement. Ethical considerations included that the guideline must direct that all patients eligible for treatment receive care (Go et al., 2014). The Self-Monitoring Implementation Guide’s educational materials were provided in Spanish and English as much as possible. The guide was designed to increase patient and provider knowledge of program availability and reduce barriers that may impede adherence to treatment for all patients, regardless of their background (Go et al., 2014). The implementation guide also promotes safety and protects patients by employing only evidence-based practice methods (Finkleman, 2022). Instrument(s) to Measure Intervention Effectiveness The project was evaluated using two questionnaires created and made available through Qualtrics. The first survey assessed whether Comagine Health accepts or rejects the guide (see Appendix A). The second survey consists of a Likert scale and write-in questions to evaluate provider satisfaction with educational materials and improvements to the clinic workflows (see Appendix B). These surveys were written with direction from Weber State faculty members and were approved by Rebecca Wilson at Comagine Health. Project Implementation The implementation of this project was complete when the guide was made available on Comagine’s website. Critical information for the guide was gathered from Comagine Health clinic surveys and Million Hearts HTN campaigns. The guide was made available to any Utah clinic free of charge and was created to offer adaptability and equal distribution to various clinics BLOOD PRESSURE SELF-MONITORING 24 and provider settings. The guide is intended to serve Utah providers and patients by providing evidence-based educational materials and workflows to meet their SMBP needs. Interventions Project interventions included a collaborative effort to identify clinic and provider needs, consultation with blood pressure management experts, and a series of revisions steered by feedback provided by these clinics and experts. Early intervention involved surveys developed by the Comagine team sent to clinics in Utah associated with Comagine Health. These surveys determined what clinic and provider resources were available and still needed. Feedback from these surveys indicated clinics needed more patient and provider educational resources and improved workflows for monitoring, initiating, and SMBP follow-up. The guide, therefore, included educational materials for providers and patients and workflow adaptation for SMBP implementation in a variety of clinical settings. The guide was created by comparing multiple evidence-based blood pressure toolkits and treatment guidelines. Educational flyers, handouts, and video links were pulled from various evidence-based guides, websites, and other scholarly sources. The educational resources were compiled in an organized fashion with three separate portfolios. The first portfolio, designed for providers, contains links, videos, handouts, workflows, and other resources for SMBP and HTN treatment and education. The second portfolio includes a handout for patients and their families to educate them on the SMBP program. The third portfolio consists of a HTN education packet for patients. The guide will be available in English and Spanish. An extensive revision process was implemented to improve the guide and ensure its efficacy and usability before publication. Dr. Woolsey and Dr. Cheng consulted to assess its effectiveness, and feedback was provided via email. The guide was also presented to the Patient BLOOD PRESSURE SELF-MONITORING 25 Family Advisory Council (PFAC) to evaluate the ease and effectiveness of use for the patients and included a pre and post-survey to evaluate feedback. Other consults included members of the Weber State Nursing faculty, a select number of clinics that work with Comagine Health, and David Cook and Rebecca Wilson at Comagine Health. Additional revisions to the guide were made from the suggestions of the consulted parties. After final modifications were made, the guide was published on the Comagine Website and reviewed by members of the guide's target population. After the guide's publication, its effectiveness was measured by two Qualtrics surveys. The first survey was for Comagine Health to assess their acceptance of the guide filling the gap in available SMBP resources. The second survey was for the clinics and providers using the guide to assess if the guide improved accessibility to educational materials and workflow. Project Timeline The project timeline included steps to obtain educational materials, develop workflows, create a functioning guide, make necessary revisions, and evaluate the guide's effectiveness. The timeline governed the project steps while keeping the Comagine team updated on the progress of the guide. Appendix E provides the project’s overall timeline in greater detail. Project Evaluation The evaluation of this project consisted of obtaining feedback on the guide from its users, namely Comagine Health, patients, providers, and clinics. Data and feedback were obtained through Qualtrics Surveys, which provided qualitative (free text boxes) and quantitative (Likert Scale) information (see appendices A-D), in addition to Zoom meetings and email communication (Appendix F). Provider feedback was obtained from Dr. Cheng and Dr. Woolsey. Patient feedback was provided by the PFAC, which represents patient needs and helps BLOOD PRESSURE SELF-MONITORING 26 to ensure that projects will be easily accessible and understood by patients. Clinics that reviewed the guide were contacts provided by Comagine Health and consisted of various community clinics and partners. Lastly, Rebecca Wilson provided feedback from Comagine Health, indicating if the guide was sufficient for the organization’s needs. Data Maintenance and Security The data was gathered using Qualtrics Surveys. The surveys were anonymous, and results were only accessible to the DNP Student. The participants were able to take the surveys privately and at their leisure. Email communication and feedback provided by Dr. Chen and Dr. Woolsey and the members of the PFAC were provided by email. The email used was a professional email address that was password protected. All feedback provided was deidentified. Data Collection and Analysis The providers offered feedback through email responses (their responses can be viewed in appendix G). The two providers indicated that the guide would be useful and that the information was up to date. One provider suggested some edits be made to the provider guide and some additional explanations be provided; these changes were added to the guide. The PFAC reviewed the guide through a Zoom meeting and provided feedback through email communication and a pre and post-survey on Qualtrics (see Appendix F). The pre and post-surveys on Qualtrics were used to evaluate how familiar the members of PFAC were with HTN lifestyle changes and their confidence level in self-measuring blood pressure. Four members of the PFAC responded to the pre-survey, and two responded to the post-survey. However, the PFAC provided more feedback through email communication than from the surveys (See appendix F). BLOOD PRESSURE SELF-MONITORING 27 Table 2 Results of PFAC pre- and post-survey Pre-Survey Post-Survey Likert Scale (n=4) (n=2) Question 1 Not at all Familiar 0 0 Slightly Familiar 1 0 Moderately Familiar 0 0 Very Familiar 1 2 Extremely Familiar 2 0 Question 2 Not Confident 0 0 Somewhat Confident 0 0 Confident 1 1 Very Confident 2 0 Extremely Confident 1 0 The guide was also distributed to clinics and providers who partner with Comagine Health and are interested in HTN management and SMBP. After reviewing the guide, these clinics were given a link to a Qualtrics survey to provide feedback. This survey included a Likert BLOOD PRESSURE SELF-MONITORING 28 Scale and free text boxes to provide feedback. The questions focused on how likely they were to use the SMBP guide, how satisfied they were with the improvements to deliver HTN services, how helpful the patient education handouts were, and how beneficial the workflow included in the SMBP guide was. Table 3 Table 3 Question 1 Very Likely (n) Likely (n) Neutral (n) Unlikely (n) Very Unlikely (n) 4 2 1 0 0 Strongly Agree (n) Agree (n) Neutral (n) Disagree (n) Strongly Disagree (n) Question 2 3 3 1 0 0 Question 4 3 3 0 0 0 Question 6 1 4 1 0 0 Note: (n) number of responses. The qualitative responses to questions 3 and 5 can be found in appendix H. One final Qualtrics survey was sent to Rebecca Wilson at Comagine Health to determine if Comagine accepted or rejected the SMBP guide. The survey question asked if they accepted the guide, accepted the guide with changes, or rejected the guide. Findings The Qualtrics survey taken by Rebecca Wilson indicated that Comagine Health accepted the guide. The PFAC provided excellent feedback through email and survey text boxes, which was used to improve the guide and make it more accessible and easier to use for patients. The BLOOD PRESSURE SELF-MONITORING 29 feedback provided by the PFAC can be found in the paper's appendices. The Likelihood of Use Survey had seven responses, which indicated that the clinics were likely to use the guide and that its educational materials improved the delivery of HTN and workflow resources. The data and information gathered indicate that the guide will be an effective tool for providers, clinics, and patients to improve HTN education and SMBP monitoring. Strengths The surveys and email communication provided vital feedback to adapt the guide to fit the needs of patients, providers, and clinics. The surveys and information collection represented the feedback, acceptance, and perspective of the patients, providers, clinics, and Comagine. Weakness The Quantitative data gathered from the PFAC pre and post-survey was not very conclusive as four responded to the presurvey, and only two responded to the post-survey. It was difficult to receive feedback from the clinics by survey, and only some survey participants completed the free text boxes on the surveys. Discussion Translation of Evidence Into Practice The scope and outcome of this project were to provide evidence-based educational materials to allow patients, providers, and clinics the tools necessary to combat HTN. High blood pressure is a "silent killer" and results in extensive damage to the physical body. Life adjustments and effective BP treatments can effectually reduce damage caused by elevated BP (AHA, 2021). A self-monitoring guide was developed to improve the management of HTN, as SMBP programs have been found to improve HTN management compared to regular office BP BLOOD PRESSURE SELF-MONITORING 30 measurements (McManus et al., 2018). Both outcomes were achieved through the creation of this SMBP guide. As a result of extensive research, it became apparent that many great resources for HTN and SMBP were widely available from various sources. However, most organizations had created various educational materials that were not structured in a fashion that could be easily accessed and utilized by a clinic. The organization of these HTN and SMBP resources attached to a workflow created a more accessible resource that many healthcare clinics could use. The feedback from the PFAC, clinics, and providers, as well as input from Comagine Health, indicated that the guide was effective and would improve patient outcomes. The feedback from providers indicated that many hoped to have this resource easily accessible within their clinics. Although the guide was comprehensive, some found it extensive, worrying that it could overwhelm patients. Some wondered how the guide would function within their clinics as it was developed to fill various clinics' needs. This knowledge could be used in the future to direct individual clinics to set goals and identify what systems and processes will function best to implement their own SMBP workflow. As the guide contains extensive resources, clinics must use them at their discretion. Some patients want to know every lifestyle and treatment option available, while others may only want to learn the basics. The guide provides most information a patient may need, and therefore responsibility falls to the individual clinic, provider, or patient to determine how they disseminate this information. These findings indicate that individual clinics must evaluate how they use this knowledge. Implications for Practice and Future Scholarship The guide was developed to be of use to various clinics, providers, and organizations. As such, it was created with the specific needs of individual clinics in mind. Further scholarship BLOOD PRESSURE SELF-MONITORING 31 might include using the guide in one of these clinics with particular adaptations to benefit the unique population of one clinic. This guide covers various topics and lists resources, but these resources could be supplemented with specific exercise, nutrition, and HTN-reducing programs local to the clinics utilizing this guide. Further workshops, education groups, provider trainings, and patient wellness groups could be developed to promote SMBP monitoring and HTN management. Members of the Million Hearts Coalition could use this guide to benefit their constituents and further develop it. Sustainability Sustainability will be achieved through regular maintenance of the guide, collaboration, and flexibility. Comagine Health will maintain the guide to ensure the content remains updated and receives additional edits as needed. Because Comagine Health is a member of the Million Hearts Coalition, which meets regularly to discuss heart health, discussions and collaboration with this coalition will aid in maintaining the guide and keeping it up to date. One of the strengths of this guide is its flexibility. The guide was designed to be adapted and used to the user's benefit. As such, adjustments will be made to ensure the needs of the clinics, providers, and organizations are met. Dissemination Distribution and dissemination of the guides will be accomplished through Comagine Health, a large nonprofit organization aimed at improving resources for a wide array of healthcare organizations in Utah. The guide will be available on their website for easy access and distribution. Members of the Million Heart Coalition were consulted throughout the evaluation of the guide. They will distribute the guide further and share it with healthcare community members. BLOOD PRESSURE SELF-MONITORING 32 Conclusion In the United States, 45 percent of the population have HTN, but only 24 percent effectively manage their HTN (Centers for Disease Control and Prevention [CDC], 2020). The average HTN patient sees a clinician four times a year, yet providers are often hesitant to treat HTN (Margolis et al., 2020). Effective multidisciplinary collaborative programs, SMBP programs, and hypertensive resources have been found to improve long-term HTN outcomes (Margolis et al., 2020; Roy et al., 2021). Comagine Health identified the need to create an SMBP guide with relevant HTN educational resources to improve long-term HTN outcomes. The development and creation of an SMBP guide, HTN educational materials, and an SMBP workflow provided effective resources screened by patients, providers, and clinics to improve hypertensive outcomes. The use and implementation of the guide and education material can help reduce complications caused by HTN, such as stroke, myocardial infarction, peripheral artery disease, heart failure, and vision loss (AHA, 2016). Effective collaboration and implementation of HTN resources between patients, providers, and clinics are the only way to help patients make effective changes to reduce and avoid the disastrous consequences of untreated HTN. BLOOD PRESSURE SELF-MONITORING 33 References Al-Noumani, H., Wu, J., Barksdale, D., Sherwood, G., Alkhasawneh, E., & Knafl, G. (2019). Health beliefs and medication adherence in patients with hypertension: A systematic review of quantitative studies. Patient Education and Counseling, 102(6), 1045-1056. doi:10.1016/j.pec.2019.02.022 American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/DNP/DNP-Essentials American Heart Association (AHA). (2021, April 18). Blood pressure toolkit. https://www.heart.org/en/health-topics/high-blood-pressure/high-blood-pressure-toolkit-resources American Heart Association (AHA. (2016, October 31). Health threats from high blood pressure. https://www.heart.org/en/health-topics/high-blood-pressure/health-threats-from-high-blood-pressure Andrusin, J., Breen, J., & Garth, H. (2018). Abstract TP379: Stroke survivors achieve good blood pressure control with nurse practitioner-led self-blood pressure monitoring program following AHA guidelines. Stroke, 49(Suppl_1). doi:10.1161/str.49.suppl_1.tp379 Atreja, A., Bellam, N., & Levy, S. R. (2005). Strategies to enhance patient adherence: Making it simple. Medscape General Medicine, 7(1), 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1681370/ Burnier, M., & Egan, B. M. (2019). Adherence in hypertension. Circulation Research, 124(7), 1124-1140. doi:10.1161/circresaha.118.313220 BLOOD PRESSURE SELF-MONITORING 34 Carey, R. M., Muntner, P., Bosworth, H. B., & Whelton, P. K. (2018). Reprint of: Prevention and control of hypertension. Journal of the American College of Cardiology, 72(23), 2996–3011. doi:10.1016/j.jacc.2018.10.022 Centers for Disease Control and Prevention (CDC). (2020, September 08). Facts about hypertension. https://www.cdc.gov/bloodpressure/facts.htm Centers for Disease Control and Prevention (CDC). (2017, October). Hypertension prevalence and control among adults. https://www.cdc.gov/nchs/products/databriefs/db289.htm Center of Disease Control and Prevention (CDC). (2021, October 14). Self-Measured blood pressure (SMBP) monitoring: million hearts®. https://millionhearts.hhs.gov/tools- protocols/smbp.html Comagine Health. (2019, April 11). Company. https://comagine.org/company Contreras, E. M., Rivero, S. M., García, E. R., López-García-Ramos, L., Vilas, J. C., Suárez, A. B., Diez, C., Vicente, G., & Claros, N. M. (2018). Specific hypertension smartphone application to improve medication adherence in hypertension: A cluster-randomized trial. Current Medical Research and Opinion, 35(1), 167-173. doi:10.1080/03007995.2018.1549026 Department of Health. (2021, December 3). Complete health indicator report of Utah population characteristics: Racial and ethnic composition of the population. Public Health Indicator Based Information System (IBIS). Retrieved from https://ibis.health.utah.gov/ibisph-view/indicator/complete_profile/RacEthPop.html Gheorghe, A., Griffiths, U., Murphy, A., Legido-Quigley, H., Lamptey, P., & Perel, P. (2018). The economic burden of cardiovascular disease and hypertension in low- and middle- income countries: A systematic review. BMC Public Health, 18(1). doi:10.1186/s12889- BLOOD PRESSURE SELF-MONITORING 35 018-5806-x Hanlin, R. B., Asif, I. M., Wozniak, G., Sutherland, S. E., Shah, B., Yang, J., Davis, R. A., Bryan, S. T., Rakotz, M., & Egan, B. M. (2018). Measure accurately, act rapidly, and partner with patients (MAP) improves hypertension control in medically underserved patients: Care coordination institute and American Medical Association hypertension control project pilot study results. The Journal of Clinical Hypertension, 20(1), 79-87. doi:10.1111/jch.13141 Institute for Healthcare Improvement (IHI) (2021). How to Improve: IHI. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx Langford, A. T., Solid, C. A., Scott, E., Lad, M., Maayan, E., Williams, S. K., & Seixas, A. A. (2019). Mobile phone ownership, health apps, and tablet use in US adults with a self-reported history of hypertension: Cross-sectional study. Journal of Medical Internet Research MHealth and UHealth, 7(1), e12228. doi:10.2196/12228 Marcello, B. C., Domenica, A. M., Gabriele, P., Elisa, M., & Francesca, B. (2018). Lifestyle and hypertension: An evidence-based review. Journal of Hypertension and Management, 4(1), 1-10. doi:10.23937/2474-3690/1510030 Margolis, K. L., Crain, A. L., Bergdall, A. R., Beran, M., Anderson, J. P., Solberg, L. I., O’Connor P., Sperl-Hillen, J., Pawloski, P., Ziegenfuss, J., Rehrauer, D., Norton, C., Haugen, P., Grenn, B., Mckinney, K., Kodet, A., Appana, D., Sharma, R., Trower, N., … Crabtree, B. F. (2020). Design of a pragmatic cluster-randomized trial comparing telehealth care and best practice clinic-based care for uncontrolled high blood pressure. Contemporary Clinical Trials, 92, 105939. https://doi.org/10.1016/j.cct.2020.105939 BLOOD PRESSURE SELF-MONITORING 36 McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed., pp.1061). Elsevier. McManus, R. J., Mant, J., Franssen, M., Nickless, A., Schwartz, C., Hodgkinson, J., Bradburn, P., Farmer, A., Grant, S., Greenfield, S. M., Heneghan, C., Jowett, S., Martin, U., Milner, S., Monahan, M., Mort, S., Ogburn, E., Perera-Salazar, R., Ahmar Shah, S., . . . & Banerjee, T. (2018). Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): An unmasked randomised controlled trial. The Lancet, 391(10124), 949–959. https://doi.org/10.1016/S0140-6736(18)30309-X Meredith, A. H., Schmelz, A. N., Dawkins, E., & Carter, A. (2020). Group education program for hypertension control. The Journal of Clinical Hypertension, 22(11), 2146–2151. doi:10.1111/jch.14022 Monahan, M., Jowett, S., Nickless, A., Franssen, M., Grant, S., Greenfield, S., Hobbs, F., Hodgkinson, J., Mant, M., R. J. (2019). Cost-effectiveness of telemonitoring and self-monitoring of blood pressure for antihypertensive titration in primary care (TASMINH4). Hypertension, 73(6), 1231–1239. doi:10.1161/hypertensionaha.118.12415 Qamar, A., & Braunwald, E. (2018). Treatment of hypertension. The Journal of the American Medical Association, 320(17), 1751-1752. doi:10.1001/jama.2018.16579 Roy, D., Meador, M., Sasu, N., Whelihan, K., & Lewis, J. H. (2021). Are community health center patients interested in self-measured blood pressure monitoring (SMBP) – and can they do it? Integrated Blood Pressure Control, 12(14), 19–29. doi:10.2147/ibpc.s285007 Sany, S. B., Behzhad, F., Ferns, G., & Peyman, N. (2020). Communication skills training for BLOOD PRESSURE SELF-MONITORING 37 physicians improves health literacy and medical outcomes among patients with hypertension: A randomized controlled trial. BMC Health Services Research, 20(1), 1-10. doi:10.1186/s12913-020-4901-8 Sheppard, J. P., Tucker, K. L., Davison, W. J., Stevens, R., Aekplakorn, W., Bosworth, H. B., Bove, A., Earle, K., Godwin, M., Green, B. B., Hebert, P., Heneghan, C., Hill, N., Hobbs, F. D. R., Kantola, I., Kerry, S. M., Leiva, A., Magid, D. J., Mant, J., . . . & Mcmanus, R. J. (2019). Self-monitoring of blood pressure in patients with hypertension-related multi- morbidity: Systematic review and individual patient data meta-analysis. American Journal of Hypertension, 33(3), 243-251. doi:10.1093/ajh/hpz182 Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., Ramirez, A., Schlaich, M., Stergiou, G. S., Tomaszewski, M., Wainford, R. D., Williams, B., & Schutte, A. E. (2020). International Society of Hypertension Global Hypertension Practice Guidelines. Journal of the American Heart Association, 75(6), 1334–1357. https://doi.org/10.1161/hypertensionaha.120.15026 Vrijens, B., Antoniou, S., Burnier, M., Sierra, A. D., & Volpe, M. (2017). Current situation of medication adherence in hypertension. Frontiers in Pharmacology, 8. doi:10.3389/fphar.2017.00100 Wall, H. K., Hannan, J. A., & Wright, J. S. (2014). Patients with undiagnosed hypertension. The Journal of the American Medical Association, 312(19), 1973-1974. doi:10.1001/jama.2014.15388 Wang, G., Zhang, Z., & Ayala, C. (2010). Hospitalization costs associated with hypertension as a secondary diagnosis among insured patients aged 18-64 Years. American Journal of Hypertension, 23(3), 275–281. doi:10.1038/ajh.2009.241 BLOOD PRESSURE SELF-MONITORING 38 Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr, Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Jr, Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Sr, . . . & Wright, J. T., Jr. (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. Journal of the American College of Cardiology, 71(19), e127–e248. https://doi.org/10.1016/j.jacc.2017.11.006 Williams, B., Mancia, G., Spiering, W., Rosei, E. A., Azizi, M., Burnier, M., Clement, D. L., Coca, A., de Simone, G., Dominiczak, A., Kahan, T., Mahfoud, F., Redon, J., Ruilope, L., Zanchetti, A., Kerins, M., Kjeldsen, S. E., Kreutz, R., Laruent, S., . . . & Desormais, I. (2018). 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). European Heart Journal, 39(33), 3012–3104. https://doi.org/10.1093/eurheartj/ehy339 Yeung, D. L., Alvarez, K. S., Quinones, M. E., Clark, C. A., Oliver, G. H., Alvarez, C. A., & Jaiyeola, A. O. (2017). Low–health literacy flashcards & mobile video reinforcement to improve medication adherence in patients on oral diabetes, heart failure, and hypertension medications. Journal of the American Pharmacists Association, 57(1), 30–37. https://doi.org/10.1016/j.japh.2016.08.012 BLOOD PRESSURE SELF-MONITORING 39 Appendix A BLOOD PRESSURE SELF-MONITORING 40 Appendix B BLOOD PRESSURE SELF-MONITORING 41 Appendix C BLOOD PRESSURE SELF-MONITORING 42 Appendix D BLOOD PRESSURE SELF-MONITORING 43 Appendix E ID Task Start Finish Notes 1 SMBP needs survey and results Jun-21 Provided by Comagine Health 2 Research on SMBP Sep-20 Dec-22 3 IRB approval from Weber State Sep-20 November 21, 2022 4 Educational Resources Development Sep-20 Jul-22 5 SMBP Clinic Surveys from clinics SMBP Jan-22 Mar-22 6 Educational Packets Completion Jan-22 May-22 7 Workflow Design Completed Jan-22 June-22 8 Review by Dr. Stults, Comagine, and Weber Faculty Apr-22 Aug-22 Review of guide and make adjustments. 9 Present to the Patient Family Advisory Council July-22 July-22 10 Final revisions and review May-22 Jul-22 11 Publish the guide on Comagine's Website Aug-22 Aug-22 12 Send out evaluation/satisfaction surveys to Comagine and community clinics. Jul-22 Sep-22 BLOOD PRESSURE SELF-MONITORING 44 Appendix F Qualitative Feedback from members of the PFAC provided by email. July 9, 2022 1. I have reviewed the Hypertension Education and Blood Pressure monitoring guide and found it to be thorough and comprehensive. I have had high blood pressure for 25 years and would have loved the explanations included in this brochure when I first was diagnosed. July 11, 2022 2. The blood pressure packet is good information. Although I have been a CNA and consider my knowledge and understanding to rank in the 8-10 range, I did not know that blood pressure issues were different for people with African descent. I think the tracking pages are fantastic. Instruction videos are good. July 20, 2022 3. All great info and I certainly learned a lot. I am concerned with the length. Many people won’t read through it all and it seems repetitive since the relationship between high blood pressure and strokes is so certain (as I read it). If that is indeed true, could you combine the info of each into one, i.e., "How can I reduce my blood pressure and risk of strokes?" Instead of having sections on each that essentially say the same thing. I would look for any other ways to shorten the document. Qualitative Feedback from the Post Survey PFAC Q2. Please share why you do or do not feel more familiar with blood pressure lifestyle changes and treatment methods than you did before reviewing the guide. Response 1: I learned things I did not know before. BLOOD PRESSURE SELF-MONITORING 45 Response 2: No response Q4. Please share why you do or do not feel more confident than you did before reviewing the guide. Response 1: I've been a CNA and have experience taking blood pressures. Response 2: I feel the same amount of confidence. I have been treated for high blood pressure for over 20 years. Q6. What about the guide was most helpful? Response 1: The tracking sheets are great. The graphics are easy to understand. Response 2: It told the effects of not treating HBP. Q7. How could the guide be improved? Response 1: No response Response 2: I was not able to use the QR codes due to an old phone. It would be helpful to have the narrative after the codes as an explanation. BLOOD PRESSURE SELF-MONITORING 46 Appendix G Provider Feedback July 29, 2022 Provider #1 Overall, it looks really good. I have some comments and suggestions in red. • I recommend that the provider guide include a brief introduction to SMBP. • Add a definition of high blood pressure in the provider guide. August 1, 2022 Provider #2 I reviewed the guide. The info is current and I would personally like to access it in a web format I could bookmark. It would be good to have it in a highly flexible format to be edited easily as the science always is changing. Comagine can keep it up. Most QI projects are best when there is content that applies to clinical champions and then the companion content for the admin and support staff. I think you have addressed both from what you said. I would advise that you try it with a clinic you are working with for some direct feedback. I would love to hear what they say. BLOOD PRESSURE SELF-MONITORING 47 Appendix H Question 3: The Blood Pressure Self-Monitoring Implementation Guide improves the clinic's satisfaction of the delivery of self-monitoring hypertension services. Please explain. 1. Like the QR codes 2. Very detailed and easy to follow for most patients. 3. The guide streamlines the process making it easier to implement. 4. No response 5. No response Question 5: The patient handouts included in The Blood Pressure Self-Monitoring Implementation Guide are useful. Please explain. 1. Very patient-centric. 2. They are clear and easy-to-read instructions. 3. They make it easy for the patient to track and report their bp readings. 4. The best way is to teach patients in clinic how to check BP as well as teach them out to write and interpret BP readings. 5. I feel like QR codes are a great way to get information, but I feel like it is a step that I easily skip; it takes me away from the information I am reading. Question 7: The new workflow included in The Blood Pressure Self-Monitoring Implementation Guide is useful. Please explain. 1. Good best practices. 2. It is useful. 3. It helps streamline the new process and includes tips on follow-up calls. BLOOD PRESSURE SELF-MONITORING 48 4. All of the information in the workflow shows exactly what the patient needs to know to effectively check BP. 5. No response.