2. BACKGROUND Chronic health conditions will account for 73 percent of all deaths globally by 2020. The economic impact on the U.S. healthcare system is $1 trillion and could increase to $6 trillion by 2050 if chronic diseases like heart disease, stroke, and diabetes are not managed in a more cost effective manner. The literature shows that poor quality of life is often linked to low socio-economic status, which in turn is linked to chronic disease. The city of Philadelphia is the poorest large city in the U.S. where over 60% of the population is a racial/ethnic minority.

3. PREVALENCE OF HIGH BLOOD PRESSURE IN TEMPLE SERVICE AREA Data from the PHMC Household Survey, 2012

4. SELF-MONITORING BLOOD PRESSURE 4 Evidence shows better control in HTN patients An increased benefit has been shown in programs that use additional support (education materials, telephonic education, electronic transmission of BP data). Patients who self monitor compared to usual care averaged a - 3.9mmHg systolic & -2.4 diastolic decrease in BP (p<.0001). (Fletcher, B. R., et al., 2016)

5. GOALS FOR TUH SMBP PROGRAM Engage patients in their healthcare Create awareness surrounding HTN self management Self-monitoring plan for HTN patients Workflow in the primary care practice ties patients self monitored readings to clinical support Achieve better BP control in HTN patients

6. KEY PLAYERS 6 Primary care physician Office staff (community health worker or medical assistant) Nurse DME company

7. TARGETING ENROLLMENT 7 Utilized the EHR to identify members in the practice with a diagnosis of HTN and an office visit within the last year Refined the list to target Health Partners Plans, Keystone First, and United Healthcare Community Plan Utilized the scheduling system to flag patients charts that were targets for the program so that enrollment could be done at time of routine office visit Assessing need for HTN program on nurse navigator transition of care calls and coordination of office visit Enrollment consisted of explanation of program, provide patient with BP cuff in office and education on use, provide hotline call in number, provide education materials and BP log to record home readings

8. WORKFLOW 8 Check hotline daily & make weekly outreach calls to collect BP readings If BP reading is >160/100 Document reading in EHR & route to physician to determine if office visit or medication change is needed Document reading in EHR & route to nurse for diet and medication review If BP reading is <160/100 Document reading in EHR under vital sign flow-sheet for review during next appointment

9. COMMON BARRIERS 9 Difficulty contacting patients due to work hours, invalid contact information, limited minutes on phone Motivation for patients to monitor on their own, lose interest and need prompt from office staff reminding to check BP Low health literacy need for repeated education at a level that is understandable for diet and medication adherence From a practice standpoint – time to execute program and incorporate outreach calls while balancing current obligations

10. PATIENT SUCCESS STORIES 10 Patient A – Ramen noodles, medication non- adherence, health literacy Patient B – Bacon and medication non-adherence Patient C – Smoker and recent stroke

11. PARTNERSHIPS 11 DME company to provide BP cuffs in office for distribution Pharmacists – assist with medication reconciliation and adherence, also assist some patients with blister packing for adherence Insurance providers – partner with case management resources for additional outreach calls to members enrolled for diet and medication education

12. NEXT STEPS 12 Data Analysis Expansion to Temple Physicians Inc. practices in increments (3 new practices starting 10/2016) Incorporate text messaging into communication

13. REFERENCES 13 References Fletcher, B. R., et al. (2016). Self-monitoring blood pressure in hypertension, patient and provider perspectives: A systematic review and thematic synthesis. Patient Education and Counseling, 99, 210-219. http://dx.doi.org/10.1016/j.pec.2015.08.026 Jia, H., Moriarty, D.G., & Kanarek, N. (2009). County level social environment determinants of health related quality of life among US adults. Journal of Community Health Online. Doi: 10.1007/s10900-009-9173-5 Moore, R. (2009). Telehealth connected care. Health Management Technology, 30(3), 40 – 39. Retrieved January 24, 2014, from Ebscohost database. Public Health Management Corporation. (2013). Temple university health system community health needs assessment. Russell, M. G., Dahrouge, S., Hogg, W., Geneau, R., Muldoon, L., & Tuna, M. (2009). Managing chronic disease in Ontario primary care: The impact of organizational factors. Annals of Family Medicine, 7(4), 309-318. Doi:10.1370/afm.982. Stanhope, M., & Lancaster, J. (2014). Public health nursing: Population-centered health care in the community (8th ed.). Maryland Heights, MO: Mosby: Elsevier. Philadelphia Department of Public Health (2014). Project narrative: DP14-1422- PPHF

14. Temple Health refers to the health, education and research activities carried out by the affiliates of Temple University Health System (TUHS) and by the Lewis Katz School of Medicine at Temple University. TUHS neither provides nor controls the provision of health care. All health care is provided by its member organizations or independent health care providers affiliated with TUHS member organizations. Each TUHS member organization is owned and operated pursuant to its governing documents.