The implementation of SMBP followed a health equity approach during the five-year program funding period (2018–2023) by leading (although not exclusively) with race and being explicit about how racism and other forms of oppression impact patients and their communities. The framework informed health center selection, data collection, and program design and implementation. In selecting the health centers, we deliberately partnered with five MA FQHCs that serve populations experiencing significant inequities. More than 90% of patients at these locations have a household income below 200% of the federal poverty level and many patients are uninsured or houseless.²² Most of the population of focus are also of Black and Hispanic or Latino populations experiencing barriers to adequate CVD care, particularly racism, discrimination, and inequitable access to resources.²² Our program design and implementation were pragmatic and flexible rather than relying on a standardized, rigid protocol to ensure that health centers had the flexibility to best serve their patients. However, the FQHCs were expected to implement key strategies: 1) Health centers must use patient registries or reports from the electronic health record (EHR) to identify and engage patients who could benefit from SMBP; 2) Patients enrolled in SMBP should be from populations that experience multiple barriers to management of blood pressure; 3) Health centers should screen patients for unmet social needs and may use complimentary strategies to increase effectiveness of SMBP and hypertension management, such as distributing tablets, providing food vouchers, linking to community resources (e.g., food pantries, housing assistance), and providing cell phones; 4) Health centers must provide blood pressure cuffs to patients and not place the burden on the patient to purchase one; 5) Non-physician team members should be engaged with patient outreach and follow up, especially community health workers (CHWs); 6) the FQHCs must engage with a vendor with healthcare quality improvement expertise to update their EHRs to support telehealth, improve in-person and telehealth clinic workflows, and increase the completeness and quality of the documentation of patient data; and 7) Non-physician team member staff must complete free blood pressure trainings offered by MDPH to ensure accurate recording of blood pressure and to facilitate training of patients.

Telehealth use increased across MA due to the onset of the COVID-19 pandemic. In addition to the 1817 cooperative agreement, the 5 FQHCs along with other healthcare organizations across the state collaborated under the FQHC Telehealth Consortium to build a sustainable, patient-centered telehealth model in FQHCs across MA.²³ The FQHC Telehealth Consortium focused on equitable integration of telehealth practices at the FQHCs, including identification of practices for strategy and leadership, clinical integration, people, and reimbursement policy.²⁴ We leveraged these broader capacity-building efforts to further facilitate implementation at telehealth at the five FQHCs.

To be eligible for enrollment, patients must be at least 18 years of age and have consistently elevated blood pressure (≥140/90 mmHg), which included both patients with uncontrolled hypertension and undiagnosed hypertension. To conduct outreach, the health centers leveraged non-physician team members, especially CHWs, with identifying candidates for SMBP enrollment. All health centers used their EHR to identify patients by reviewing retrospective blood pressure values using registries and reports during a six-month to one-year timeframe. To facilitate accurate and valid blood pressure values, baseline blood pressure measurements were obtained after patient completed training on proper blood pressure technique and measurement, which was typically within one week to a month after enrollment. MDPH did not require a strict timeline on when the baseline blood pressure measurement needed to be recorded to provide the FQHCs with flexibility during the pandemic.

The goal of enrollment in the SMBP program was to achieve blood pressure control. The blood pressure goal was set as <140/90 mmHg, however health centers could set a lower target goal based on the patient’s individual needs.

As recommended in SMBP clinical guidelines, the duration of patients’ enrollment in the SMBP program was based on the discretion of physicians at the health centers.¹⁴ On average, the participants in our case series study stayed in SMBP programs for 106.81 days (SD=7.56). Each FQHC had a target of enrolling and collecting study data for 50 patients over two years (n=250 total). Given that the program was pragmatic in nature and the numerous challenges the health centers faced during the pandemic, the sample size of 50 per FQHC was selected based on the capacity of the health centers rather than statistical considerations.

Blood pressure cuffs were either given to patients without an expectation of return or through a loaner program depending on the funding source that the five FQHCs used to purchase the cuffs (purchasing of cuffs is not authorized under thise study’s federal funding source). The health centers would provide the cuffs to the patient at an in-person visit to provide a lesson on how to properly use it and then schedule a telehealth follow-up visit with a non-physician team member such as a nurse or CHW. When informing patients on how best to manage their blood pressure at home, staff also provided a patient education tool developed by MDPH entitled “On the Path to a Healthy Heart” which advised patients on how to lower their blood pressure and cholesterol through daily eating and exercise habits. This fact sheet was available in English, Spanish, Haitian Creole, Portuguese, and Traditional and Simplified Chinese. Figure S1 displays this education tool.

Synchronous telehealth visits were conducted by phone call or video conferencing. Additionally, patients were able to report blood pressure readings to their care team through the EHR patient portal, such as MyChart, in some subawardee health centers. During the telehealth visit, blood pressure measurements from SMBP enrollees were then reviewed by a member of the clinical team, such as a physician, nurse, or CHW and documented in the EHR ideally in a structured field or as a note.

We conducted a prospective case series study to evaluate the effectiveness of the SMBP programs implemented in the five FQHCs. Patients were prospectively enrolled from November 2021 to July 2023. The five FQHCs reported the first and last home blood pressure cuff readings from the participants along with the dates of the readings and demographics of the participant including age (continuous), sex (male, female, not reported), race (Asian, Black, Native American/Alaskan Native, Native Hawaiian/Pacific Islander, White, not reported), ethnicity (Hispanic or Latino, non-Hispanic or Latino, not reported), and language (English, Haitian Creole, Spanish, Portuguese, Chinese, Russian, Vietnamese, French, Cape Verdean Creole, Khmer/Cambodian, Nepali, Arabic, American Sign Language (ASL), Laotian, and other specified languages). The first blood pressure was after enrollment into the SMBP program taken at home after the patient received training on proper blood pressure measurement. The last blood pressure is after the patients’ completion of the SMBP program or at six months after enrollment, whichever came first. Study data were collected in REDCap.

In alignment with the a priori racial equity lens, we conducted subpopulation analyses of systolic and diastolic blood pressure changes by the race, ethnicity, and language of the participants. Blood pressure was treated as a continuous variable and evaluated using a paired t-test after ensuring test assumptions were met. A Shapiro-Wilk test was conducted to evaluate whether a data was normally distributed. If the normality assumption of the t-test was violated, the Wilcoxon signed ranks test was conducted instead. To account for varying times in which the patient was enrolled in the SMBP program, we also evaluated overall changes stratified by length of SMBP enrollment. Due to multiple pairwise comparisons, we set alpha a priori at 0.01 to reduce the risk of a type 1 error. All statistical analyses were conducted using R Studio version 4.2.1.

We analyzed 241 SMBP participants in total. These participants were mostly Black (61.8%), non-Hispanic (70.5%), female (51.5%), English-speaking (50.6%), 45 years or older (83.6%), and were enrolled in their SMBP program for less than 90 days (54.8%). Table 1 summarizes these data.

The five FQHCs were successfully able to engage with their patients to equitably implement telehealth SMBP programs during a global pandemic. Further, at the conclusion of the data collection period, over half of SMBP participants experienced a decrease in their blood pressure. Improvements in blood pressure were also observed by race, ethnicity, and language. Our findings indicate that a holistic, equity-focused implementation of SMBP via telehealth can effectively reach populations marginalized by multiple adverse social determinants of health. These populations are often underserved by the healthcare system and may be overlooked in implementation of SMBP programs. Our study demonstrates that these populations can be successfully engaged in SMBP programs under settings with limited resources.

The health centers reported that there has been a newfound appreciation for CHWs and their unique ability to connect with and understand the social needs of the priority population. They were a key part of patient identification, enrollment, and follow-up in the SMBP programs. Due to the rapid transition to telehealth, the health centers had to re-train staff on adjusted workflows for providing CVD care in a remote environment. Non-physician team members, particularly CHWs, had enhanced roles among the CVD care team and needed further education on blood pressure management. MDPH providing free non-physician blood pressure trainings was critical to ensure that blood pressures were accurate and to facilitate training of patients to take their blood pressure at home. Furthermore, the critical partnerships leveraged by the five FQHCs with community-based organizations (CBOs) helped to fill in the gap in providing resources for health related social needs that FQHCs cannot provide, including food pantries, YMCAs, and non-profit organizations that specialize in reducing barriers to healthy living including insecurities around food, housing, finances, transportation, and childcare. The health centers reported that their most successful partnerships were due to an openness to discussion regarding patient needs, a reliable workflow for providing resources, and bidirectional communication.

FQHCs reported that challenges to SMBP implementation largely centered around implementing telehealth technology and workflows. This required updating EHR systems, adjusting clinical workflows, overcoming unfamiliarity of telehealth models, adopting an equitable and standardized form of blood pressure cuff distribution, and connecting with patients that had an unreliable form of remote communication such as internet issues or lack of access to a smart device. In the initial stages of the COVID-19 pandemic and SMBP program implementation, non-physician staff did report challenges with provider engagement in care plans for SMBP participants. Additionally, there was high staff turnover during the pandemic, thus it was difficult for health centers to prioritize who received SMBP and telehealth trainings.

However, there are multiple successes to note derived from the challenges. Health centers reported that the support of their information technology (IT) teams to revamp their EHRs to be more user-friendly in remote care was invaluable, which greatly assisted with having a patient’s information organized and ready to be used at each SMBP telehealth visit. Additionally, despite the difficulties with blood pressure cuff distribution, health centers reported that they were able to develop workflows for patient distribution and education on how to use them. Further, using pre-existing registries and EHR reports for identifying patients with uncontrolled and/or undiagnosed hypertension eased challenges in identification of patients for enrollment. Non-physician blood pressure trainings provided by MDPH increased physicians’ confidence in their teams to conduct accurate blood pressure readings and provide education to patients on how to manage their hypertension at home.

Our study has limitations to note. There was heterogeneity in SMBP implementation across the five FQHCs because the patient populations had unique needs and resource availability at the health centers varied. Consequently, our evaluation strategy had to reflect this heterogeneity and our findings should be interpreted in this context. The time between the initial and final blood pressure measurements varied for each patient as the length of time the patient was enrolled in the SMBP program was at the discretion of the provider. Additionally, one health center provided data on only 41 SMBP participants due to limited staffing. Although we note significant improvements in blood pressure, regression to the mean may partially be responsible for the observed reductions in blood pressure because patients’ technique of taking their own blood pressure likely improved over the duration of the program. However, the study requiring that patients have consistently elevated blood pressure prior to enrollment may partially mitigate this.