Helping Neighborcare Patients Know Their Numbers

blood pressure cuff

The American Heart Association has collaborated with Neighborcare Health to encourage patients to be active participants in their health by managing their high blood pressure.

Neighborcare is the Seattle area’s largest provider of medical, dental and behavioral health care services for low-income and uninsured people, seniors on fixed incomes, immigrants and unhoused individuals in the Seattle area.

By supporting the implementation of a self-monitoring blood pressure program at seven Neighborcare clinics in summer 2021, over 56,000 patients now have access to more tools, resources and education to manage their hypertension and reduce their risk of life-threatening complications such as heart disease and stroke.

For more than 50 years, Neighborcare Health has provided compassionate, quality care to Seattle's most vulnerable community members, regardless of ability to pay. Neighborcare Health clinics are composed of diverse care teams and intentionally located in neighborhoods where health disparities are the greatest, to help increase access to important preventive health care.

For the blood pressure initiative, the AHA team provided 350 patient care kits with hypertension management tools including automatic blood pressure devices with instructions to ensure accurate measurements, plus pill organizers, digital scales, magnetic boards and pedometers. To educate and guide participating patients, the AHA provided resources on how to measure accurately, understand blood pressure readings and make lifestyle changes to lower high blood pressure.

By equipping patients with their own blood pressure device, the self-monitoring program helps address some barriers, including lack of transportation, that may prevent people from tracking their blood pressure.

"The Neighborcare Quality Team worked with the nursing and clinical education teams to incorporate the patient kits into the appropriate workflows at the seven clinics that have received them, and patients are getting important health education and helpful resources as a result," said Alyssa Caucci, quality manager at Neighborcare.

The AHA worked with Neighborcare to collaboratively develop protocols to train providers and patients on self-monitoring, identify eligible patients for the program and distribute devices. To ensure consistency and accuracy of in-clinic measurements, the AHA provided automated office blood pressure machines to participating clinics.

Clinic care teams can input and review home blood pressure measurements in the patient's electronic health record to monitor progress and adjust care plans when additional support is needed. To track overall hypertension control rates, Neighborcare reviews aggregate data by location and demographics and implements quality improvement strategies accordingly.