When a patient is willing to partner with their physician in gaining control of high blood pressure, the results can be rewarding for both parties. That partnership is both important and surprisingly simple. A resident physician gives an inside look at how her medical center implemented self-measured blood pressure (SMBP) monitoring and is engaging patients in the advancement of their own health.
At Family Health Center at Medstar Franklin Square in Baltimore, physicians incorporated SMBP monitoring in their practice in a way that has helped patients with high blood pressure take control of their health.
The practice implemented SMBP monitoring when it collaborated with the AMA and Johns Hopkins Medicine as part of the M.A.P. program—measure accurately, act rapidly and partner with patients, families and communities), said Crystal Peralta, MD, a third-year resident physician at Franklin Square.
“Our project is a culmination of ideas that we brainstormed together as a team,” Dr. Peralta said. “It also incorporates ideas that we gathered from other family programs who were experiencing success with their own home blood pressure monitoring initiatives.”
Patient engagement was initially very high and has continued to grow at Franklin Square.
How patients are identified for SMBP
The practice began incorporating SMBP into its regular routine as an effort to more accurately identify the true blood pressures of its patients. Studies show that patients’ pressures often are elevated when they are in the office and often are not a true reflection of their blood pressure in their daily environment, Dr. Peralta said.
“By using our [electronic health records], we’ve identified the patients who have had continued elevated blood pressure” above goal, based on the clinical guidelines the practice follows, she said. “We’ve highlighted every one of those patients on each clinician’s roster.” The clinicians are then responsible for contacting their patients and encouraging them to follow up in the office. At that point, the clinicians offer the patients an opportunity to participate in SMBP monitoring.
“We’ve included patients with hypertension, patients with white coat hypertension, patients with elevated blood pressure with a confirmed diagnosis, patients who have had a recent history of pre-eclampsia,” she said. “It’s basically open to everybody—and it’s a decision that the physician and the patient make together.”
“So far the response has been wonderful,” she said. “We have seen that once patients are actively participating in their care by taking their pressures daily, they are eager and so motivated to improve their health.”
It all begins when a patient comes into the office for an office visit. “Our medical assistants know that when a patient has a blood pressure that is elevated above [goal], they automatically take out a laminated, neon orange card that says ‘140/90: Make a change; follow up in 2-4 weeks,’” Dr. Peralta said. “The card is left right on the keyboard in the room so that the physician sees the card when they sit down and start writing their notes. It’s a really good stop-and-pay-attention sign because it can’t be missed.”
After addressing the elevated blood pressure, the physician gives the patient the opportunity to participate in SMBP monitoring. Any patient can participate if they meet three criteria:
- Two blood pressure readings above 140/90 during the office visit
- The patient’s arm circumference is within limits of the blood pressure cuff size
- The patient exhibits the motivation and willingness to improve their blood pressure
Getting started
“We offer them the opportunity to take home a blood pressure cuff for approximately 14 days,” Dr. Peralta said. “We have 15 automated blood pressure machines at the moment. We started off with only five, but the program became so popular that we had to buy 10 more. Even with the 15 we have, they are always signed out, and there is often a waiting list for a monitor, so we are looking at hopefully buying a few more in the near future.”
The practice’s medical assistants are trained in the protocol and are key to the success of the project, she said. “It really is a team effort. Between the office staff, the medical assistants and clinicians, we all play a huge role.”
“We have a package of handouts and other materials that the physicians along with the medical assistants review with the patient,” she said. “First, the physician educates the patient on what high blood pressure means, then discusses effective ways to improve their pressure through things like diet, exercise, medication compliance, etc. We review a handout about the DASH diet and spend a lot of time walking them through step-by-step instructions on how to take their blood pressure properly with the monitor we provide to them.”
Before they leave the office, the patient has to demonstrate that they are able to take a proper blood pressure.
“The patients are very appreciative when we offer them a monitor to take home,” Dr. Peralta said. “The truth is that many of our patients may not be able to afford a monitor. Some may not even truly understand the importance of having a monitor at home, and so this is a great way for us to educate our patients, increase their awareness, and provide them a resource that they may not have been able to otherwise access.”
“Patients who have never taken their own blood pressure before tell me how pleasantly surprised they are at how easy it is to take their blood pressures properly,” she said. “The machines that we have are very user friendly.”
Patients must schedule a follow-up visit for two weeks later before they leave the office and begin the 14-day measuring program.
How it works
Patients are asked to take their blood pressure readings two times in the morning at least one minute apart and two times in the evening. To encourage active participation, the patient is responsible for recording their readings. There is also a column for comments, where they can list any factors that might have contributed to a high blood pressure reading, such as recent exercise, coffee or fast food consumption, or getting into an argument.
“It helps them to be more aware of what they’re doing in a day that might be elevating their pressures,” Dr. Peralta said. “It makes them more aware of their diet. It makes them accountable and aware of what might be contributing to their high blood pressures.”
“We advise that after a week they should check in with us. Either the physician will call the patient, or the patient calls us,” she said.
“At the two-week visit, if their blood pressures have been within goal, the physician might decide that the patient has completed the program and continue to encourage the patient to stay the course and further improve upon the lifestyle changes they have made,” Dr. Peralta said. If the patient’s pressures continue to remain elevated above goal, then the patient and physician come up with a plan together. This plan may include medication adjustments, additional blood work or nutrition counseling. The patient also might continue on in the monitoring program for another 14 days to see how the changes affect the patient’s blood pressure.
“Sometimes patients will come in, and if they haven’t had their blood pressure taken properly, they’ll tell the physician, ‘I was supposed to be sitting down with both feet flat on the ground, and I didn’t get it done that way this time.’ Some people tell us stories of how they are now able to teach other members of their family how to properly take a blood pressure,” she said. “It’s really great when you see your patients grow. They first present understanding very little about what hypertension even means and then transform into advocates for healthier living in their own families and communities.”
Get started in your practice
Access the AMA-Johns Hopkins Medicine M.A.P. resources to implement SMBP monitoring in your practice. The resources cover everything from selecting an SMBP device to patient training on how to self-measure correctly to hypertension diagnosis and management.
For more on SMBP
- Learn 4 ways to promote better BP during National High Blood Pressure Education Month
- Find out why you should use SMBP
- Learn what you need to start SMBP in your practice
- Examine expert insights into the latest blood pressure trials and guidelines
- Use the one graphic you need for accurate blood pressure reading
