Community-Based Blood Pressure Monitoring Programs

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.

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.