Deploying telehealth for equitable hypertension management

SMBP can help underserved populations access hypertension treatment

Underserved populations across the country, which include racial and ethnic minorities, low-income populations and immigrants, face numerous barriers to healthcare access. These access barriers are mirrored in Massachusetts, where underserved populations face poverty, racism and other adverse SDOH like lack of access to technology, according to Janet Spillane, public health nursing advisor and health systems specialist at MDPH.

She said that these barriers hinder hypertension care for patients in the state in several ways, including by preventing them from purchasing expensive BP cuffs. Further, there is a lack of healthcare materials at the appropriate literacy levels, leaving underserved populations without the patient education needed to use BP cuffs and other tools for hypertension management.

SMBP programs facilitated via telehealth can be an effective hypertension management approach for this population as they provide the tools needed, enable patients to quickly and conveniently connect with healthcare providers, and eliminate transportation challenges.

Research has highlighted telehealth's efficacy in hypertension treatment. A study published in 2022 showed that the care quality of telehealth-based treatment for high BP was similar to that of in-person treatment. Not only did the study find no significant difference in blood pressure decreases between in-person and telehealth patients over time, but patients who used telehealth were also more satisfied with the treatment.

Further, the Community Preventive Services Task Force (CPSTF), established by HHS for community-based health promotion and disease prevention, published a systematic review on the effectiveness of SMBP with clinical support to manage high BP, said Leah Greene, an MDPH epidemiologist. The Million Hearts initiative, developed by the Centers for Disease Control and Prevention (CDC) in 2012, also released several recommendations on SMBP program implementation and execution.

Thus, clinical evidence and health agencies support telehealth-based SMBP programs as "an effective, evidence-based practice," Spillane noted. However, she added that studies must also evaluate equity-focused implementations of SMBP among underserved communities.

Though telehealth-based SMBP programs have the potential to alleviate various care access barriers, implementation processes that do not consider equity could result in new hurdles to care access. For instance, lack of access to reliable broadband internet can hinder telehealth access among underserved groups.

To ensure that the Massachusetts-based FQHCs selected to implement the telehealth-based SMBP program did not inadvertently increase care gaps, MDPH researchers evaluated the health equity-focused implementation process, detailing challenges and strategies to overcome them. They published their findings in the Journal of Public Health Management & Practice.

Implementing telehealth-based hypertension management

The telehealth-based SMBP program allows patients to monitor their blood pressure at home and connect with healthcare providers to control their hypertension.

Caroline Wetzel, MDPH's director of diabetes and cardiovascular disease programs, said that following enrollment, patients are given BP cuffs for free and shown how to use them.

"The health centers provide the cuffs to the patient at an in-person visit to provide a lesson on how to properly use them, and then schedule a telehealth follow-up visit with a non-physician team member such as a nurse or community health worker," she explained.

The FQHC staff also provides patients with a patient education tool developed by the MDPH. The tool offers information on daily eating and exercise habits that can help lower blood pressure and cholesterol. The fact sheet is available in English, Spanish, Haitian Creole, Portuguese and Chinese, Wetzel said.

The patients then take the cuffs home and report their BP readings to their care team through their EHR-based patient portal. The care team reviews the measurements with the patients during the telehealth visit. These measurements inform patient care plans for hypertension control.

Health equity was front and center during program implementation, with MDPH considering racism and other forms of oppression affecting patients and their communities, Wetzel said. The health equity framework informed health center selection, data collection and program design.

For instance, MDPH deliberately selected five FQHCs that serve populations experiencing significant inequities.

"Most patients at the five FQHCs have a household income below 200% of the federal poverty level, were uninsured or houseless, and were Black and Latino experiencing barriers to adequate cardiovascular care, particularly racism, discrimination, and inequitable access to resources," Wetzel said.

Greene stated that the program design and implementation were largely flexible, allowing FQHCs to implement strategies that would best serve their patient population rather than forcing all the facilities to follow a standardized protocol.

However, some strategies were expected to be implemented by all FQHCs. For instance, FQHCs were asked to enroll patients from populations that experience multiple barriers to hypertension care and to screen patients for unmet social needs, Greene said.

Additionally, FQHCs were required to "engage with a vendor with healthcare quality improvement expertise to update their EHRs to support telehealth, improve in-person and telehealth clinic workflows, and increase the completeness and quality of the documentation of patient data," Greene said.

Still, FQHCs were allowed to use some complementary strategies to increase the effectiveness of the program, such as providing food vouchers, linking patients with community social services and providing cellphones.

Overcoming implementation hurdles

As the FQHCs worked through the telehealth-based SMBP implementation process, several challenges emerged. Spillane explained that the main obstacles to implementation centered on technology infrastructure and workflows.

"[The implementation] required updating EHR systems, adjusting clinical workflows, overcoming unfamiliarity of telehealth models, adopting an equitable and standardized form of blood pressure cuff distribution, and connecting with patients who had an unreliable form of remote communication such as internet issues or lack of access to a smart device," she said.

Additionally, FQHCs had to contend with high staff turnover, which affected the program's rollout.

Nonphysician team members played a critical role in helping the FQHCs overcome these challenges. In particular, community health workers, who had a unique understanding of the culture, experiences and needs of the patient population, were able to provide insights that helped ensure a health equity-focused implementation.

The multilingual community health worker teams supported the enrollment of patients with limited English proficiency and connected patients with unmet SODH needs to community resources, Greene said.

"In most of the FQHCs, community health workers were heavily involved in patient outreach, engagement and follow-up," she added.

MDPH supported the success of community health workers in this area by providing free non-physician BP measurement training to ensure the accuracy of in-clinic BP readings and patient training for home BP measurements.

The telehealth-based SMBP program aims to help patients achieve BP control, typically defined as a BP of less than 140/90 mmHg but could also be lower based on patients' individual needs.

To determine whether the health equity-focused program achieved this goal, MDPH researchers examined data for 241 patients enrolled in the program from November 2021 to July 2023 across the five FQHCs.

They found that a little over half (53.5%) of SMBP participants experienced a decrease in blood pressure, with an average reduction of 10.06/5.34 mmHg from 146/87 to 136/81 mmHg.

"Improvements in blood pressure were also observed by race, ethnicity and language," Wetzel said. "Our findings indicate that a holistic, equity-focused implementation of SMBP via telehealth can effectively reach populations marginalized by multiple adverse social determinants of health."

Not only that, but the FQHCs reported a newfound appreciation for community health workers and their ability to connect with underserved groups.

The promising study results show that telehealth-based SMBP programs can be implemented effectively and equitably in low-resource settings caring for vulnerable populations. This highlights that virtual care, when implemented through the lens of health equity, can enhance chronic disease management.

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.