Team-Based Care to Improve Blood Pressure Control

Introduction

CDC's Division for Heart Disease and Stroke Prevention's (DHDSP) Best Practices Clearinghouse promotes team-based care as a part of a comprehensive treatment protocol for hypertension management.12

The Community Preventive Services Task Force (CPSTF) recommends team-based care as an effective way to improve blood pressure control among all populations.3 They also found team-based care interventions to be cost-effective.

* Public health practitioners and state and local health departments can support use of this CPSTF recommendation by highlighting the benefits of team-based care and supporting health systems and organizations with implementation.

* Public health interventions that cost less than $50,000 per quality-adjusted life year (QALY) are widely considered cost-effective.

Key findings

Strategies that support implementing team-based care to improve blood pressure control

When implementing team-based care, team members can share responsibilities to support the care plan developed by the patient's primary care provider.

Strategies that team members can use to implement team-based care to improve blood pressure control include the following:

Patient follow-up. 4Team members can support patients after their visits with their primary care provider. This could include the following:

• Designing or facilitating the use of a patient self-management plan.
• Using technology to stay in regular contact with patients and improve adherence to their self-management plans.
• Regularly confirming appointments and treatment plans.

Medication management. 5Achieving blood pressure control often requires adjusting medication doses to find what works best for the patient. Qualified team members may support this process by making recommendations to the primary care provider or independently managing medications. Pharmacists may engage in medication management using the Pharmacists' Patient Care Process and Collaborative Practice Agreements to implement collaborative drug therapy management.

Medication adherence support. 6 Patients may face barriers to taking their medications as prescribed. Team members can help patients improve adherence by identifying and working to address these barriers with education and coaching. CPSTF recommends tailored pharmacy-based interventions to improve medication adherence.7

Self-management support.8 Lifestyle changes, including adopting a healthy diet, getting more physical exercise, maintaining a healthy weight, reducing stress, and not smoking, can be difficult to make and maintain. Team members can support and empower patients to take an active role in controlling their high blood pressure. Strategies include health behavior counseling, coaching, and education.

Self-measured blood pressure (SMBP).910 Patients may benefit from regularly using home blood pressure monitors to measure and record blood pressure. CPSTF recommends SMBP interventions either alone or in combination with additional support to improve blood pressure control outcomes. Team members can collaborate to educate, train, and support patients' regular use of SMBP devices.

The foundation of team-based care is organizing care so a multidisciplinary team can work together to meet patients' needs.

Four interventions have been shown to facilitate incorporating the strategies listed above into the successful implementation of team-based care.3

Facilitate communication and coordination of care support among team members. Patients engaged in team-based care receive clear and unified messaging from their primary care providers and other team members.3 This supports better patient care and balances team member workload, and may also help reduce clinician burnout.325 Consider clearly defining team member roles and preferred communication methods;3 using electronic health records, email, telephone, or other digital tools; and using digital technology and telehealth to allow for co-visits with primary care providers and other team members.

Enhance the use of evidence-based guidelines by team members. Guideline-directed treatment can improve management of high blood pressure.24 Applying standardized, evidence-based treatment protocols has been shown to support consistency in care across diverse patient groups.24 Consider using clinical guidelines, which summarize available evidence, to inform treatment protocols that incorporate a team-based care model to enhance patient care.2

Establish regular, structured follow-up mechanisms to monitor patients' progress and schedule additional visits as needed. Regular, timely follow-up can improve adherence to blood pressure self-management plans and increase patient contact.67 More frequent follow-ups may help overcome clinical inertia (delays in starting or adjusting treatment).68 Consider designing follow-up protocols to use heath technology to regularly communicate with patients and assess patients' health status and whether treatment needs to be adjusted. 67

Actively engage patients in their own care. Patients who have the knowledge and support to manage their blood pressure are more likely to know their numbers, take prescribed medications, and make healthy lifestyle changes.89 Patients who use SMBP with direct clinician support are more likely to achieve blood pressure control.10 Consider having team members using digital health tools to provide health behavior counseling, coaching, or education to empower patients and support blood pressure management.10

Conclusion

The CPSTF found that team-based care is a cost-effective intervention to improve blood pressure control.3 Uncontrolled high blood pressure is a preventable risk factor for cardiovascular disease and a major driver of health care costs. Health problems caused by uncontrolled blood pressure, such as heart failure, heart attack, kidney disease, and vision loss, can be chronic and affect multiple body systems.

According to the 2020 Surgeon General's Call to Action to Control Hypertension, total medical costs associated with uncontrolled blood pressure in the United States are estimated to be $131 billion to $198 billion each year. For individuals, health care services cost about $2,500 more per year for people with uncontrolled blood pressure than for people who do not have uncontrolled high blood pressure.

The cost of blood pressure management is lower than the long-term costs associated with hypertension's many complications. The major costs of implementing team-based care were team member labor and communication tools.

Cost savings noted by the CPSTF were due to averted costs of health care through inpatient stays, emergency department visits, outpatient visits, labs, and medications, and improved productivity of patients due to their improved health status.

As state and local health departments consider introducing or expanding these interventions in their communities, an important first step is bringing together partners who will implement the interventions so that the interventions can be tailored to the communities' needs. Key considerations include the partner organizations' capacity, the health care professionals involved and their roles in patient care, and the mechanisms for reimbursement for team-based care services.1

Resources

State and local health departments and public health practitioners play an important role in promoting and supporting evidence-based strategies. The "Identify-Assess-Act" framework can help inform local communities' use of the following tools and resources to improve team-based care. (Note that many of the resources are cross-sectional and can support a range of steps in various interventions.)

Identify

Identify patient populations or communities that face a disproportionate rate of high blood pressure.

Practitioners and health departments can take a number of different steps:

• Map populations with high rates of uncontrolled blood pressure that may benefit from team-based care.
• Map the prevalence of heart disease with social and economic data.
• Identify specific needs in the community, as well as team member roles that may have the greatest impact and accessible locations or settings.

The following resources may assist in identification:

• Interactive Atlas of Heart Disease and Stroke. This online mapping tool allows users to create and customize county-level maps of heart disease and stroke by race and ethnicity, sex, age group, and more.
• Chronic Disease Map Gallery. This is an online forum for sharing maps and resources for chronic disease prevention.

Assess

Assessments often consider the facilitators and the barriers to implementing team-based care interventions, as well as the setting, policies, and regulations. For example, local health departments can take one or more of the following steps to facilitate the assessments:

• Describe existing programs that use innovative or unique team-based care approaches that may be replicated.
• Identify recurring challenges or barriers to implementing team-based care.
• Investigate how to fill the roles needed for the team-based care team (for example, encouraging the fulfillment of those roles through training or incentive programs).
• Assess available resources, staffing, costs, and the population's needs.
• Determine which policies support team-based care.
• Consider funding opportunities.

The following resources may assist in assessing the facilitators and the barriers to implementing team-based care interventions:

• The CDC Health Systems Score Card. This tool can be used regularly to identify areas of primary care practice that might need to be refreshed or enhanced.
• Community-Clinical Linkages for the Prevention and Control of Chronic Diseases: A Practitioner's Guide. This document offers guidance to public health practitioners on key strategies to implement community-clinical linkages that focus on adults 18 years old or more.

Act

Implement team-based care interventions with strategies that complement the CPSTF recommendations. For example, local health departments can act by doing the following:

• Sharing information and resources with community and clinical partners and supporting implementation.
• Supporting information sharing, education initiatives, and expansion of effective models.
• Supporting evaluation activities where team-based care has been implemented.

The following resources may assist in acting to implement team-based care interventions:

• Hypertension Management Program (HMP) Toolkit. This is an online interactive training for a team-based, patient-centered, integrated care model.
• Pharmacists' Patient Care Process Approach Guide. The goal of this implementation guide is to support public health practitioners' engagement of pharmacists in blood pressure management through the Pharmacists' Patient Care Process (PPCP).

Disclaimer

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