Blood Pressure Monitoring at Community-Based Organizations

Connecting At-Risk Residents to Medical Care for High Blood Pressure

Community-Based Blood Pressure Monitoring (Community-Based BPM) programs use a community-based organization to provide onsite blood pressure screenings for the community members that organization services. The organization is provided with supplies and educational materials for community members to measure their blood pressure on an automatic blood pressure cuff, receive health education to understand their screening results and provide referral information to medical services to ensure follow-up care. This programming targets individuals with uncontrolled hypertension who may have a medical home or who are not under the care of a medical provider, assisting them in identifying medical services that meet their needs. 

The Goal of Community-Based BPM Programs

One of the overarching goals of Community-Based BPM is to increase the number of community-clinical linkages within communities and throughout our state in order to improve chronic disease prevention, care and management. These linkages help ensure that people with or at high risk of chronic diseases, such as high blood pressure, have access to community resources and support (such as BPM programs) to prevent, delay or manage chronic conditions.

Establishing a Community-Based BPM Program

A community-based BPM program meets members of your community where they are – at the local barbershop, their workplace, or church. The BPM site educates community members on the symptoms and risks of high blood pressure, takes blood pressure readings, and if needed, connects them to a medical home. Some BPM sites train staff members to take blood pressure readings using an automatic blood pressure cuff. Others have a health professional present to manually take blood pressure readings. The readings are recorded and shared with the participant and partnering healthcare organization. Participants that already have an established medical home are encouraged to share their readings with their provider during their next appointment. Participants without a medical home, who have elevated readings, receive follow-up care from the partnering healthcare organization. If a participant receives an elevated blood pressure reading at the BPM site, he/she is directed to the emergency room of the partnering healthcare organization. Below are examples of locations where community-based BPM have successfully been implemented:

  • Libraries
  • Workplaces
  • Pharmacies 
  • Walgreens, CVS, Walmart
  • Barbershops or Beauty Salons
  • Faith-Based Organizations (typically within a Health Ministry)
  • Non-Profit Organizations (YMCAs, Councils on Aging, Food Banks)

When establishing a community-based BPM, these steps must be followed.

  • Step 1: Identify Community-Based BPM Roles

    Within community-based BPM programs, there are different key stakeholders and roles they play in the planning, building and sustaining a community-based BPM program! The assigned responsibilities below can be shifted between roles based on the capacity of the different key player identified. The most important part is that all pieces are assigned to a designated stakeholder. The breakdown below is simply an idea of how responsibilities have been successfully distributed in previous projects.

    Community Champion:

    • Additional partners such as local health system, hospital, independent practices, federally qualified health centers (FQHCs), rural health centers, etc. can be identified to further support the program.
    • Identify/provide screening locations. Locations should exhibit readiness to provide blood pressure screenings to community members.
    • Readiness includes that participants are available for screening and the site understands and is willing to accommodate program requirements, able to participate in trainings as needed, and the site is comfortable referring participants to health systems when screenings indicate immediate action is needed.
    • Bring all major partners and stakeholders together for regular meetings/trainings where decisions about workflow are discussed and made.
    • Ensure consistent, regular communication with BPM program sites and as needed, deliver additional supplies to BPM program sites and/or identify funding source (mini grants) to support BPM program site supplies.
    • Assist in design of the BPM program site workflow for collecting blood pressure readings.
    • Locate additional healthy behavior community resources to refer at-risk participants when applicable.
    • Create and supply a consent form to participants that clearly informs them what data is being collected, what it will be used for and how it will be stored.

    Healthcare Organization:

    • Have the ability to diagnose and treat high blood pressure and willingness to accept BPM program referrals.
    • Work with community champion and Well-Ahead to establish and implement workflow for collection of blood pressure readings. Things to consider when designing workflow include: frequency of screening, who is taking the participant’s blood pressure, are there any additional measures being taken, when and where are the screenings taking place.
    • Provide aggregate data points to Well-Ahead Louisiana on a monthly basis.
    • If applicable, ensure that all volunteers are trained on proper blood pressure collection, education, and referral. The healthcare organization should also ensure that all volunteers understand the Health Insurance Portability and Accountability Act (HIPPA) and the healthcare organization’s protected health information (PHI) protocol.
    • If applicable, provide trained clinic/health system staff to collect blood pressure readings at the BPM program sites.
  • Step 2: Choose a BPM Guiding Model

    Once roles and responsibilities have been assigned, the next step to building a successful community-based BPM program is to select a program model that fits the community. Selecting a program model ensures that a closed referral loop from the BPM site to the healthcare organization is created. This loop leads hypertensive and at-risk patients to the medical care needed to decrease their risk and assist them in gaining a medical home.

    These models provide adaptable structures that identify program participants within a community who currently do not have an established medical home. The participants will be identified in the BPM program site and referred to the healthcare organization providing support to the BPM program site. With community-based recruitment for BPM program there are several models that can be selected. The primary difference between the models is the individual who is assisting the participants to conduct the blood pressure readings.

    Health System Staff Facilitated: 

    The clinic/health system supporting the BPMP conducts on-site screenings to collect client blood pressure readings. They also provide participants with on-site education, follow-up, and referral care to those who report elevated blood pressure readings.

    Model perks:

    • Personal Health Information (PHI) is collected and reported by the clinic staff
    • No additional training of volunteer community members or BPM program site staff is required
    • Health system staff can provide onsite health education as it directly relates to the reading taken that day.

    Model downfalls:

    • Health system staff are needed to conduct regular onsite screenings, taking them away from their regular duties.
    • Screenings are only conducted during the hours that the health system staff are onsite

    Volunteer Facilitated: 

    Volunteer community member(s) conduct screenings at the BPM program site. If possible, recruitment of medically experienced volunteers (for example, registered nurse, certified health coach, or medical assistant) is preferred but not required. All volunteers will complete training on protocol for screening, health education and referral.

    Model perks:

    • No additional strain is put on the BPM program site or supporting health system to conduct the screenings.
    • Staff resources are not absorbed to conduct BPM program onsite screenings.

    Model downfalls:

    • Additional training is required for screening, education and referral staff.
    • Handoff of PHI from BPM program site to clinic site is required.
    • Screenings are only available during the hours that the volunteer is onsite.

    Community Champion Site Facilitated: 

    Community organization staff is identified and recruited to conduct screenings, health education, and referral of the individuals participating in the program.  Additional training is needed for individuals conducting screenings, providing education and referring to support the clinic.

    Model perks:

    • Utilizes a trusted relationship as cornerstone to conducting the blood pressure readings.
    • Availability of screening is much broader than other models.

    Model downfalls:

    • Additional training is required for screening, education and referral staff.
    • Handoff of PHI and potential storage of PHI prior to delivery to health system.
    • May require legal paperwork, etc.

Technical Assistance

Well-Ahead is here to help you identify key program partners and establish a primary contact for both the Community Champion and Healthcare Organization. We help guide and support the planning and implementation of community-based BPM programs.

Well-Ahead provides:

  • Provide technical assistance on BPM program best practice and overcoming barriers.
  • Offer adaptable template forms and documents for program implementation.
  • Post project kick-off, to provide follow-up and project support as needed to produce continued outcomes.

The resources below will help you implement community-based BPM programs and help your patients properly self-measure their blood pressure.

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Community-Based Blood Pressure Montoring Resources

After setting up your community-based BPM program, you can utilize these resources at your organization.

Resources for Providers

Resources for Patients