Abstract 15921: Reaching Patients With Hypertension: A Model of Remote Blood Pressure Monitoring Plus Team-Based Care

Abstract

Background: Social determinants of health (SDoH) significantly impact hypertension (HTN) control, yet are not addressed as part of the medical model. We used a team-based approach, integrating remote blood pressure monitoring (RBPM), pharmacists, and community health workers (CHWs) to address HTN among patients with persistently uncontrolled HTN referred from cardiology fellows clinics. This study assesses the impact of this model in achieving BP control. Methods: Pharmacists screened patients for SDoH using a tool adapted from the Accountable Health Communities initiative and managed BP during biweekly virtual visits. Patients with SDoH were referred to Project Access-New Haven for CHW support. We describe clinical characteristics, SDoH, program metrics, and BP changes among the first 100 patients. We also assessed predictors of BP control (< 130/80 mmHg) using multivariable logistic regression. Results: Among referred patients, multiple SDoH were identified; 18% of whom accepted support by a CHW (Table). BP decreased from a mean of 154/86 mmHg to 135/78 mmHg (mean reduction 20/8 mmHg). BP control was associated with greater medication adherence, having diabetes and competing health priorities. There was no association between SDoH and BP control. Conclusions: A team-based care model with pharmacists and CHWs was effective in reducing BP among low income patients with multiple SDoH and persistently uncontrolled HTN. SDoH was not associated with achieving BP control, suggesting that this model may overcome or attenuate SDoH impacting BP control. Still, half of patients did not achieve BP control, highlighting the need for continual partnership and program improvement.