The Use of Targeted Nursing Interventions and Telehealth to Address SDOH and Manage Hypertension

Purpose: Hypertension (HTN) has been identified as the most common medical diagnosis in the US and individuals with social, economic, and cultural factors have higher prevalence and poor control of their ability to self-manage the disease. HTN has also been associated with the highest risk for mortality related to cardiovascular disease. Care coordination and the use of community health workers to provide resources, especially those related to social determinants of health (SDOH), can improve patient engagement, support improved quality of care, and can potentially cascade into improved health and well-being outcomes.
Methodology: Using the PDSA methodology, the following EBP research project was implemented: 1) Two chronic disease nurses filtered a facility-specific chronic disease dashboard to identify patients ages 40-75 with a clinical diagnosis of HTN and uncontrolled B/P ≥140/90 after two PCP visits.
2. Motivational interviewing was used to identify patients who did not express or exhibit readiness for self-care management, which was used as exclusion criteria.
3. For the patients who met the inclusion criteria (n=51), the nurses implemented targeted nursing interventions over a 3-month period (April 2023 to June 2023) which included: a) comprehensive patient education tailored to the individual patient’s needs, b) home B/P monitoring with log book, c) collaborative care planning, d) monthly outreach via telehealth check-in and in-person nurse visits, and e) SDOH screening and referrals to CHWs for internal/external resources as indicated.
Analysis: Within a 3-month period, 76% of patients with uncontrolled HTN reduced their clinic B/P from ≥140/90 to ≤130/80 (n=34). Monthly telehealth outreach/education and SDOH screening were completed in 100% of the patients (n=51). SDOH were addressed using grant-funded home B/P devices for patients with financial needs (n=12; 24%) and CHW referrals for housing, food, transportation, smartphone access, educational, employment, and legal assistance resources (n=7; 14%).
Results: This quality improvement project showed that 76% of patients with clinic B/P ≥140/90 improved their clinic B/P to ≤130/80 over a 3-month period. Using telehealth outreach services and addressing SDOH can support engagement and quality patient outcomes.
Learning outcomes: 1) Discuss the relationship between social determinants of health and hypertension. 2) Describe the targeted nursing interventions used in hypertension management. 3) Identify multiple modes used to address the social determinants of health.