Community Health Workers Address Patient Social Needs to Control Blood Pressure in the ADDRESS-BP Project (Actions to Decrease Disparities In Risk and Engage In Shared Support For Blood Pressure Control In Blacks)

Challenge
High blood pressure, or hypertension, is a major risk factor for cardiovascular disease, a group of conditions that affect the heart and blood vessels and which is the leading cause of death in the United States. Though well-controlled blood pressure can lower the risk of stroke, heart attack, and heart failure, less than half (48%) of adults in the United States with hypertension have controlled blood pressure. Certain groups are disproportionately affected. In New York City, Black adults have the highest rate of hypertension (44%), compared to Latino/a (31%), White (23%), and Asian/Pacific Islander (22%) adults (1). Barriers to patients achieving hypertension control exist at multiple levels.

Solution
The integration of Community Health Workers (CHWs) into primary care teams is an evidence-based strategy to improve blood pressure control, noted by the Community Guide and Agency for Healthcare Quality and Innovation. CHWs are frontline public health workers who are trusted members of the communities they serve and act as a bridge between health systems and social services, facilitating access to services and improving the quality and cultural competence of service delivery.

The ADDRESS-BP Project (Actions to Decrease Disparities in Risk and Engage in Shared Support for BP Control in Blacks) uses a tailored practice facilitation and CHW implementation strategy that supports the implementation of a multi-level, evidence-based intervention using remote blood pressure monitoring, nurse case management, and social determinants of health (SDOH) support to address patient-, physician-, health system-, and community-level barriers to hypertension control among Black patients receiving services at NYU Langone Health (NYULH) primary care practices in New York City.

ADDRESS-BP CHWs support nurses by engaging patients through 1-on-1 interactions or group sessions, either in-person or remotely, to enhance adoption of the intervention by: 1) preparing patients to be active participants in their care; 2) conducting educational meetings to support nurse counseling around blood pressure control; and 3) supporting patients to enhance adherence to remote blood pressure monitoring and nurse counseling visits and developing strategies to encourage and problem-solve around challenges. CHW implementation strategies in this project were informed by the Expert Recommendations for Implementing Change (ERIC) Framework (2).

Impact
ADDRESS-BP CHWs have demonstrated measurable impact at the first 2 NYULH primary care practices the team has engaged with since 2024. CHW efforts target high-risk patients and contextualize patients’ life circumstances to address social needs and improve blood pressure management. To date, they have conducted over 40 health education sessions and 10 coaching calls with patients to set health behavior goals and address challenges, provided 10 referrals to address social needs, and provided technical support to 26 patients related to their remote blood pressure monitor. Project CHWs leverage their close community ties and extensive knowledge of community resources and networks, built up from decades of experience conducting street outreach and working with community- and faith-based organizations to promote health screenings and provide community-based education on hypertension prevention and management.

As the examples below demonstrate, the project CHWs have worked with patients to address social needs across the spectrum – from accessing affordable healthy foods and medical devices, to setting goals to improve health behaviors related to diet, exercise, and stress management.

1. Addressing Food Insecurity: A CHW met with a patient who was struggling to make ends meet and experiencing food insecurity. Busy with part-time school and a part-time job, his priority was affording meals and housing, which meant he had less time to focus on addressing his hypertension. The CHW focused on food insecurity as the primary social need; she first identified food pantries within the patient’s zip code, then mapped out the types of foods available (e.g. hot meals versus groceries, free vs. low cost) by day of the week. She recommended strategies to help the patient maximize his resources (e.g. stockpiling food every day) so that the patient could save more to put towards housing, bills, and transportation. The patient was very grateful for the resources provided by the CHW, which created trust in their relationship. Resolving his challenges with food insecurity allowed him to focus more on his health and feel more motivated to upload his blood pressure readings every day, which in turn, enhanced his engagement and his blood pressure improved.

2. Improving Health Behaviors: A CHW met with a patient who was overweight and having difficulty losing weight. Through their conversation, the patient expressed that she had a poor diet and ate a lot of takeout, and wanted to do better for her body. The CHW encouraged her to visit the local farmers markets and learn about different vegetables that she might like, and also coached her on how to improve her health behaviors. The patient started walking, signed up for a gym membership, and drank more water, and has lost 27 lbs. so far.

3. Coping with Stress: A CHW met with a patient who said they drank alcohol to cope with stress and felt pressure to drink from her social circle. She felt defeated in keeping a healthy diet: “drinking is unhealthy so I might as well eat unhealthy as well”. The CHW collaborated with the patient to identify tips/ideas to eating healthy and cope with stressors. Changing her health behaviors led to the patient lowering their BP (160/90 to 135/86), losing 6lbs and reducing their drinking from 6 to 2 drinks per week. The CHW was able to do this by helping the patient set realistic SMART goals that were achievable “instead of having 6 drinks per week let’s cut it to 4 drinks per week”. By helping the patient identify an achievable goal rather than “all or nothing” approach, which allowed them to attain a lifestyle change, rather than a temporary unrealistic goal that would be challenging to maintain.

4. Accessing Medical Devices: A patient with hypertension and Ehlers-Danlos Syndrome, a condition that affects the body’s connective tissues, needed help with referral to a specialist and accessing medical devices needed for her mobility. The CHW referred her to Bridging Access to Care, which is working with her to receive a wheelchair and medical bed. As a result of working with her CHW, the patient expressed that she feels more confident and motivated to advocate for herself with her providers.

5. Technology assistance and remote blood pressure monitor set up: Overall, CHWs focus much of their efforts in assisting patients with technology, specifically by setting up their remote blood pressure monitor to their electronic health record via Bluetooth. The CHW team has assisted 26 patients in connecting their monitor and providing further assistance throughout the project for those whose set up disconnects, require technical updates, or have challenges submitting readings to their patient portal.

Involvement
Informed by implementation frameworks, the ADDRESS-BP Project re-conceptualizes CHW efforts as an implementation strategy to support multi-level interventions for blood pressure control. CHWs can support blood pressure management in primary care settings in a number of ways, including through engaging patients with technological barriers, linking patients with culturally-relevant health information that reinforces nurse health coaching, better equipping patients with strategies to understand blood pressure treatment plans and communicate concerns to their healthcare team, and understanding and addressing social needs and “upstream” factors that serve as barriers to patients in managing their high blood pressure.

References

(1) Dominianni C, Seltzer B. Hypertension prevalence, awareness, treatment, and control in New York City. New York City Department of Health and Mental Hygiene: Epi Data Brief (135); January 2023.

(2) Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kirchner JE. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015 Feb 12;10:21. doi: 10.1186/s13012-015-0209-1. PMID: 25889199; PMCID: PMC4328074.