Multi-ethnic Multi-level Strategies and Behavioral Economics to Eliminate Hypertension Disparities in Los Angeles County

"Patient-focused strategies to increase HTN management practices:~1. Hypertension registry: notify patients of their status, target education and resources to patients~2. Home BP monitoring: provide BP monitors, encourage reporting of home BP readings~3. Enhance standardization of home and office BP readings: patients trained by care staff, posters in clinics on how to measure BP correctly~4. Nurse-directed BP medication titration with CHW/Health Educator reinforcement: self-directed referrals to nurse-directed clinics and CHW/health educators~5. Enhance patient understanding of BP using culturally- and linguistically- tailored materials: tailored educational materials offered to patients in clinic, via text and the patient portal.~6. Social needs screening and linkage to community resources: awareness of and self-referrals to community resources~7. Behavioral science intervention messaging: posters in clinic waiting rooms, scripts for RN/PCP, texts to patients"

"Provider-focused strategies to increase HTN management practices:~1. Hypertension registry: identify patients with uncontrolled BP, notify care team~2. Home BP monitoring: provide home BP monitors, encourage reporting of BP readings~3. Enhance standardization of home/office BP readings: staff training, posters in clinic~4. Simplify treatment protocols using fixed-dose combo meds: education on fixed-dose combo meds~5. Nurse-directed BP med titration w/ CHW/Health Educator support: system for team-based care, referral to nurse-directed clinics \& CHWs/health educators~6. Enhance patient understanding of BP using culturally- and linguistically- tailored materials: Increased availability of tailored materials~7. Social needs screening and linkage to community resources: referral system to resources~8. CHW assigned to patients with complex medical and social needs: referral of complex patients to CHWs~9. Behavioral science messaging: posters in charting rooms, scripts for RNs"

A combination of the 7 patient-focused strategies (see patient-focused strategies outlined above) and 9 provider-focused strategies (see provider-focused strategies outlined above) implemented simultaneously.