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Engaging Patients and Providers in Partnership to Prevent Heart Disease, "The Middlesex 4P Program"
Engaging Patient and Providers in Partnership to Prevent Heart Disease, “The Middlesex 4P Program” is a clinical education video about a self-blood pressure monitoring pilot project.
The project utilized a team-based quality improvement initiative that addressed blood pressure (BP) control by applying a care coordination system to promote patient-centered care and self-management behaviors in an intensive self-blood pressure monitoring program.
“The Middlesex 4P Program”offers intensive home blood pressure monitoring (HBPM) and treatment adjustments using multiple approaches including patient recorded BP readings; nurse telephone calls to patients to review self-management goals and lifestyle changes, follow-up office visit with N/CC for monitoring, education, and self-management; and medication adjustment by providers. This team-based care coordination intervention provided close follow-up and support in the form of a Nurse/Care Coordinator (N/CC) who worked individually with patients empowering them to set their own goals and monitor their own BP at home. N/CCs were trained in Motivational Interviewing and Self-Management Goal Setting.
Fifty two adult patients with diagnosed HTN were enrolled in the program and received a home BP monitor and taught how to monitor two times per day. Patients received weekly or bi-weekly calls from N/CCs to review BP readings, SMGs and overall care plans. One-month follow-up office visits were conducted to review BP trends, SMGs and reinforce medication usage and lifestyle changes. All information was documented and shared with PCPs who adjusted medications and make recommendations as needed.
The goal was to design a care coordination system that is efficient, effective, and integrated into an existing clinical delivery system. The measurable product is a systems-level intervention that utilizes best practices and integrates care coordination for patients with poor HTN control into the primary care delivery system.
Learning Areas:
Chronic disease management and preventionClinical medicine applied in public health
Learning Objectives:
List three risk factors for hypertension.
Describe components of effective multidisciplinary team-based self-management for hypertension, a transferable model which can be applied to other chronic diseases.
Describe the significance of Motivational Interviewing for managing uncontrolled hypertension.
Explain the importance of patient empowerment and goal setting for managing uncontrolled hypertension.
Keyword(s): Chronic disease management and prevention, Clinical medicine applied in public health
Qualified on the content I am responsible for because: I am a Certified Health Education Specialist with an MPH, own a private public health/healthcare consulting company, have served as Adjunct Faculty in the Public Health Department at SCSU for the past 8 years, have 10 years of public health experience, and seven years of hospital administrative experience, completed all levels of training for the Middlesex 4P Program including Train-the-Trainer, and am currently working with the CT DPH to implement the Program statewide.
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.