Actions to Decrease Disparities in Risk and Engage in Shared Support for Blood Pressure Control (ADDRESS-BP) in Blacks

项目总结/摘要：由于以下障碍，黑人的高血压（HTN）控制不理想： 患者、卫生系统、提供者和社区护理水平。虽然护理案例的功效 管理（NCM）和家庭血压监测（HBPM）是行之有效的;这些策略不 解决社区一级的障碍（不稳定的住房，交通），以充分控制高血压，从而限制 对黑人的影响。将社区卫生工作者（CHW）纳入初级保健，以帮助患者 浏览社区资源是有效的HTN控制患者经历社区水平的障碍。 尽管这些多层次循证干预措施（NCM、HBPM和 在真实的世界初级保健实践中，大多数少数群体患者 接受护理，是次优的。这一建议利用实践促进（PF）-一个理论上合理， 可持续实施战略，以评估国家协调机制、HBPM和CHW的实施情况， 综合社区-诊所联系模式[实践支持和社区参与（PACE）]， 解决病人，医生，卫生系统和社区层面的障碍，以HTN控制在黑人。我们将 在NYU Langone Health的20个主要实践网络中测试PACE的实施情况， 纽约市，与一个既定的社区诊所学术咨询委员会和健康第一（纽约市的 最大的医疗补助支付者）。实践促进者将协助实践将NCM和HBPM整合到诊所中 6个月的工作流程，之后重新评估患者的血压控制状态;对于那些仍然保持血压控制状态的患者， 不受控制的情况下，促进者将协助实践制定将CHW添加到护理中的流程 团队帮助患者浏览社区资源，并解决社区层面的障碍，以实现最佳的HTN 控制NCM包括家庭BP远程监测、行为咨询和药物调整/滴定 训练有素的护士。受过培训的社区卫生工作者与护士合作，加强护理协调， 健康指导和实践与社区资源之间的双向转诊。我们会进行 拟议的研究分为两个阶段：1）UG 3阶段，将使用基于社区的可持续发展原则 研究和实施研究的综合框架，以制定一个针对具体情况的PF 战略; 2）UH 3实施阶段，将使用普罗克特的实施成果框架， 在一项包含20项初级保健实践的阶梯楔形群随机对照试验中，对500名黑人患者进行了评价， HTN，PF策略对PACE临床和成本效益的影响。我们还将研究收养 和实施保真度作为潜在的机制，可以解释PF对BP控制的影响。初级 结果是从基线到18个月的血压控制。次要结局是PACE的成本效益。的 研究结果将提供一个实用和可持续的系统，利用现有的临床和社区， 资源建设初级保健实践的能力，以管理少数群体中的HTN控制。

PROJECT SUMMARY/ABSTRACT: Hypertension (HTN) control in Blacks is sub-optimal due to barriers at the patient, health systems, provider, and community-levels of care. Although the efficacy of nurse case management (NCM) and home blood pressure monitoring (HBPM) is well-proven; these strategies do not address community-level barriers (unstable housing, transportation) to adequate HTN control, thus limiting their impact in Blacks. Integration of community health worker (CHWs) into primary care to help patients navigate community resources is effective for HTN control in patients experiencing community-level barriers. Despite their efficacy, implementation of these multi-level evidence-based interventions (NCM, HBPM, and use of CHWs) into routine care in real world primary care practices, where a majority of minority patients receive care, is suboptimal. This proposal harnesses practice facilitation (PF)- a theoretically sound and sustainable implementation strategy to evaluate the implementation of NCM, HBPM, and CHWs delivered as an integrated community-clinic linkage model [Practice support And Community Engagement (PACE)] to address patient-, physician-, health system-, and community-level barriers to HTN control in Blacks. We will test the implementation of PACE across a network of 20 primary practices within NYU Langone Health in NYC, in partnership with an established Community-Clinic-Academic Advisory Board and HealthFirst (NYC's largest Medicaid payer). Practice facilitators will assist practices to integrate NCM and HBPM into the clinic workflow for 6 months, after which the patients' BP control status are re-evaluated; and for those who remain uncontrolled, the facilitators will assist practices to develop processes for the addition of a CHW to the care team to help patients navigate community resources and address community-level barriers to optimal HTN control. NCM comprises home BP telemonitoring, behavioral counseling, and medication adjustment/titration by trained Nurses. Trained CHWs work in partnership with Nurses to enhance care coordination, and provide health coaching and bi-directional referrals between the practices and community resources. We will conduct the proposed study in two phases: 1) a UG3 phase that will use principles of Community-Based Participatory Research and the Consolidated Framework of Implementation Research to develop a context-specific PF strategy and; 2) a UH3 implementation phase that will use Proctor's Implementation Outcomes Framework to evaluate, in a stepped-wedge cluster RCT of 20 primary care practices in 500 Black patients with uncontrolled HTN, the effect of the PF strategy on clinical and cost-effectiveness of PACE. We will also examine adoption and implementation fidelity as potential mechanisms that may explain the impact of PF on BP control. Primary outcome is BP control from baseline to 18 months. Secondary outcome is cost-effectiveness of PACE. The study's findings will provide a practical and sustainable system that harnesses existing clinical and community resources to build capacity for primary care practices to manage HTN control in minority populations.