The national organizations (CDC, NACHC, Y-USA, and ASTHO) came together to establish project goals and coalesce around a common definition of SMBP. SMBP was defined as a method for individuals with hypertension to take regular measures at home using a home blood pressure monitor sufficient to establish a meaningful pattern of data to manage treatment. A completed SMBP protocol was defined as a patient monitoring their blood pressure at home with at least two measurements a day, morning and evening, for three consecutive days then reporting back to their clinician.

The national team inventoried tasks required to support a patient completing an SMBP protocol. Many of these tasks, such as educating patients on using a home blood pressure monitor, subsidizing home blood pressure monitors (e.g., loaning or providing), and training patients on how to communicate blood pressure measurements back to the care team, have been previously identified [10]. Required and optional tasks were detailed.

Tasks were separated by what absolutely must be done by a licensed clinician and those that must be done by the patient. That left tasks that can be accomplished by a non-clinical person—what we will refer to from this point forward as a “SMBP Supporter” (see Table 1: SMBP Tasks by Role).

Local health center/community organization/public health teams determined how they could accomplish the tasks detailed by the national team. Local teams assembled tasks into a functional approach or protocol. Teams focused on adapting existing evidence-base primary care practices around SMBP [7] while leveraging unique capacities and resources available through community organizations and public health partners to support their SMBP efforts.

The national team developed the SMBP model design checklist (see Fig. 1: SMBP Model Design Checklist with Key Questions). This checklist is organized into five domains: SMBP scope, key SMBP staff, SMBP patient identification and support activities, SMBP data management, and community linkages. Each domain includes specific questions that need to be answered on the local level. The checklist, along with the detailed tasks and roles were used by the local teams to create clinical protocols and workflows to support hypertension patients using SMBP. When possible, these included public health and community resources.

Teams used quality improvement methods, including workflow and information flow analysis, Plan-Do-Study-Act cycles [11], and annotated run charts to design, test, refine, and implement collaborative SMBP clinical protocols and workflows.

To support health centers and their community and public health partners as they developed their collaborative SMBP approaches, we convened a learning community with monthly knowledge sharing opportunities for subject matter experts and peers. The learning community, which we called our “All Teams Call”, provided a forum to go over key tasks and best practices.

NACHC, Y-USA and ASTHO also held monthly calls with project participants to enable peer to peer learning, capture leading practices, and support program/partnership implementation.

Health centers began implementation by identifying adult patients, 18 to 85 years of age who might benefit from SMBP. Health center care teams recommended patients with uncontrolled primary/essential hypertension (defined as a systolic blood pressure ≥ 140 mmHg or a diastolic blood pressure ≥ 90 mmHg) for SMBP based on individual health center protocols, typically through health information technology registry identification and a recommendation or referral from medical providers. From July 2017 to June 2018, identified patients were offered training on SMBP. Patients were given or loaned a monitor and educated on how to use it. The education included proper preparation and positioning to obtain an accurate measurement and how to communicate blood pressure measurements back to the care team. For those using Bluetooth-enabled monitors, patients received training on an associated app that sent measurements to an online portal accessible to their care team. Patients were supported via follow-up phone calls, patient portal messages, and/or text messages.

A summary of clinic and partner characteristics helps set the stage for program implementation. Table 2 provides a profile of these partnering health centers and collaboration partners.

Some health centers referred all patients recommended for SMBP to community programs and required that they had to agree to use SMBP and also to attend the community program, in order to be counted as an SMBP participant. Other health centers risk stratified their patients, suggesting those who had blood pressure levels up to 160 mmHg systolic or 100 mmHg diastolic utilize community programs to receive lifestyle support, while patients with blood pressure levels ≥ 160 mmHg systolic or ≥ 100 mmHg diastolic received more intensive counseling and education offered by the health center. Once a participant achieved a level of blood pressure < 160 mmHg systolic and < 100 mmHg diastolic, then they were referred to a community program. Patients were identified as having utilized a community program only when they were referred and also agreed to attend. Some health centers had internal staff who could offer lifestyle support services. Patients who were offered lifestyle support programs at their health center were not referred to a community program.

Qualitative data were obtained via a face-to-face meeting of all participating organizations and through semi-structured interviews.

The face-to-face meeting took place in March 2018, where health center, Y, and public health teams presented and described their SMBP processes from start to finish. These presentations were standardized by a PowerPoint template that included partners, SMBP patient selection criteria, community referral criteria, patient identification process, patient recommendation/enrollment/training approach and SMBP data management. These also included a reflection about what is unique, innovative, or powerful about each team’s approach, recommendations and lessons learned, and workflow diagrams. Collaborative approaches to implementing SMBP were summarized to understand the varying collaborative models and to detail tasks completed by non-clinical partners.

Key informant semi-structured interviews with each health center project lead occurred in May and June 2018. These covered the nature of their community/public health partnerships, how these partners were integrated into SMBP approaches, sustainability plans, and lessons learned. Each interview was audio recorded and transcripts were entered into NVIVO 12 Plus [12]. We identified specific questions from the interview guide and their associated answers prior to analysis and coded for thematic inferences.

Monthly reports aggregated at the health center level included number of patients recommended for SMBP, referral to a community program, and patient use of SMBP. These data were collected via a combination of electronic health records (EHR) or population health management system documentation and manual tracking. Most health centers did not have standard places in the vital signs section of their EHR for out-of-office blood pressure measurements or other standard places to document SMBP-related data elements. Five health centers customized their health information technology (HIT) systems to allow for the entry of out-of-office measurement and related SMBP data elements to their systems and were able to report SMBP measures electronically; others tracked out-of-office blood pressure measurements and SMBP-related data using Microsoft (MS) Excel spreadsheets.

This study was determined to be exempt by the AT Still University – Arizona Institutional Review Board (IRB) from continuing IRB review. Interviews with key informants were performed with verbal consent, aggregated, and anonymized, and written consent was not collected. A waiver of written informed consent was granted based on 45 CFR 46.116(d): “Obtaining written consent would be the only way in which interviewees could be linked to their responses.”

All nine health centers developed different approaches to implementing SMBP. Table 3 illustrates the various SMBP-related tasks in emerging collaborative approaches that were accomplished by health centers, community organizations, or public health agencies in this project. Eight of the nine health centers established collaborative approaches where external organizations assisted with tasks we identified that could be performed by an SMBP Supporter.

Community and public health organizations assisted most with: providing home blood pressure monitors; providing healthy lifestyle education; reinforcing training on use of a monitor; reinforcing training on capturing and relaying home BP values and reinforcing knowledge of behaviors that can trigger high blood pressure.

In New York, all four participating health centers worked with the New York State Department of Health, which purchased home blood pressure monitors so they could be loaned to patients for SMBP. At the local level, three New York health centers referred patients out to a local Y program, and the fourth center had their health center staff become certified as Y Healthy Heart Ambassadors to deliver the Y program at their health center. One New York health center also partnered with their local public health agency to conduct outreach calls and home visits to patients to support their SMBP use after they had taken a monitor home, while another worked with their local public health department to obtain educational resources that would support their SMBP efforts. Finally, one of the New York health centers worked with Americorps [13] volunteers to assist their care teams with SMBP training and data management.

In Kentucky, one site partnered with a local university to have pharmacy students train patients on SMBP inside the health center, while another site within this same health center organization partnered with a local public health department, which completed outreach phone calls to patients who had taken home a home blood pressure monitor.

In Missouri, one health center established regular office hours (2 days per week) for local Y staff to deliver the local Y program on location at their health center. The local Y staff were woven into their SMBP model to provide initial training on SMBP to patients as well as SMBP reinforcement and healthy lifestyle education. A second Missouri health center collaborated with multiple partners, including the American Heart Association, who assisted with purchasing home blood pressure monitors and delivering healthy lifestyle education at the health center, as well as the local Y, to which the health center also referred patients.

Most health centers also sought other kinds of collaboration as part of their overall SMBP approach not indicated in Table 3 to help enhance supports or address barriers around hypertension control (e.g., additional lifestyle education or exercise opportunities, transportation services, fresh food pantries, etc.). Figure 2 depicts an example of a workflow that one health center created with its local Y partner detailing various roles and patient flow designed to accomplish all the necessary SMBP tasks.

Key informant interviews of health center staff sought to reveal whether clinical-community collaborations helped support SMBP adoption and what elements were important for successful collaborations. The primary theme that emerged was that collaborations were beneficial where a “win–win” situation could be created for both the health center and community-based organization (CBO). Some health centers forged new partnerships after assessing their current SMBP needs and sharing this information with their local health department, who then helped the health center consider available capabilities offered by CBOs equally eager to discover new clientele to whom they might offer beneficial services.

Three sub-themes surfaced: (1) learning about CBO assets relevant to supporting SMBP, (2) establishing trust, and (3) developing an empowered working relationship between clinical and CBO staff. Three health center interviewees shared that learning about available community resources was a critical first step in successful collaboration. Others commented on the importance of being able to trust the CBO. For partnerships with local Ys, trust came from knowing the local Ys use certifications and tested training curricula. “With their Healthy Heart Ambassadors, I know that once those people get selected or hired, they are put through a training… They actually have to go through some sort of certification…”.

Health centers that developed new or expanded upon existing partnerships often found that staff from CBOs and/or local public health departments could operate as a part of the expanded care team, sharing information bi-directionally (and confidentially) about SMBP patients. “All…sets of staff…were coordinating with all the different patients but the burden of who was tracking was reduced from the collaboration.” It was important that partners empowered each other to do the work they were tasked with while providing the space and opportunity to function in the best interest of the patient. This empowerment distributed the burden of supporting SMBP and enabled partnerships to provide sustainable healthy lifestyle support and address barriers to SMBP related to costs, transportation, and access to home blood pressure monitors.

By the project’s conclusion the nine participating health centers reported that 1421 patients with uncontrolled hypertension received a recommendation or referral to SMBP. Of those, 795 successfully completed at least one SMBP protocol (SMBP use). In addition, 308 of the 1421 patients received referrals for additional community program support. Health center implementation dates varied between June 2017 and January 2018 (Fig. 3).