Identifying Successful Strategies for Implementing Team-Based Home Blood Pressure Monitoring in Primary Care

高血压是预防心血管疾病的一个最重要的、医学上可改变的危险因素， 疾病在美国。控制高血压对改善老年人的生活质量和寿命至关重要。 美国和解决心血管疾病的种族差异。然而，国家在 控制高血压的工作停滞不前。美国目前的高血压护理模式依赖于 几乎完全是在临床医生驱动的办公室访问，已被证明是不够的。我们迫切需要一个团队- 以病人为中心的护理模式。家庭血压监测（TB-HBPM） 代表了一种在初级保健中广泛使用不足的循证实践。需要战略 以促进其在初级保健中的采用。根据已公布的采用TB-HBPM的障碍，成功 战略必须让患者和临床医生参与实施过程，并为患者和他们的 护理团队拥有实施和维持TB-HBPM所需的知识、技能、资源和数据。 值得注意的是，战略必须解决财务可持续性问题。该提案的主要目标是确定 并严格评估可翻译的战略，以实施和维持TB-HBPM 初级保健.为了实现这一目标，我们将从一个单一的网站招募七个做法， 控制不理想。这些做法主要服务于低收入和少数民族患者。在第1阶段（R61）， 我们将召集一个指导委员会，包括病人，实践工作人员和临床医生，以指导规划， 实施、可持续性和评价（目标1）。在第一阶段，我们将评估具体的障碍， 促进者在这些实践中实施TB-HPBM。基于这些具体做法的障碍，我们将 使用实用、稳健、实施和可持续性模型（PRISM）实施战略。在 在第2阶段（R33），我们将使用混合型2、阶梯式楔形集群部署这些实施策略 随机试验（目标2）。实施策略将包括患者和团队培训、可操作的数据 提供给团队，并采用新的计费代码。我们将评估实施的影响 使用覆盖、有效性、采用、维护（RE-AIM）框架（目标3）的战略。我们的首要 结果将是HTN控制和患者使用HBPM。次要结局将包括以下比例： 60天内就诊的血压不受控制的患者，由团队建立团队章程 （采用）和基于成本分析的财务可持续性（维护）。我们将使用现实主义评估 测试实施战略的理论假设（目标4）。这种混合方法 这种方法将使我们能够为其他环境开发可转移的经验教训。我们的发现将推动科学 实施成功的HTN管理模式，并提供更广泛的路线图 在初级保健中实施TB-HBPM。

Hypertension is the single most important, medically modifiable risk factor for the prevention of cardiovascular disease in the United States. Control of hypertension is critical to improving the length and quality of life in the United States and for addressing racial disparities in cardiovascular disease. Yet, national progress in controlling hypertension has stalled. The current model for hypertension care in the United States, which relies nearly exclusively on clinician-driven office visits, has proven inadequate. There is an urgent need for team- based, patient-centered models of care. Team-based home blood pressure monitoring (TB-HBPM) represents an evidence-based practice that is widely underused in primary care. Strategies are needed to promote its adoption in primary care. Based on published barriers to adoption of TB-HBPM, successful strategies must engage patients and clinicians in the implementation process, and provide patients and their care teams with the knowledge, skills, resources, and data needed to implement and sustain TB-HBPM. Notably, strategies must address financial sustainability. The primary goal of this proposal is to identify and rigorously evaluate translatable strategies for implementing and sustaining TB-HBPM within primary care. To accomplish this aim, we will recruit seven practices from a single site where hypertension control is suboptimal. These practices serve predominately low-income and minority patients. In phase1 (R61), we will convene a steering committee that includes patients, practice staff, and clinicians to guide planning, implementation, sustainability, and evaluation (Aim 1). During phase 1, we will assess the specific barriers and facilitators to implementing TB-HPBM within these practices. Based on these practice-specific barriers, we will operationalize strategies using the Practical, Robust, Implementation, and Sustainability Model (PRISM). In phase 2 (R33), we will deploy these implementation strategies using a hybrid type-2, stepped wedge cluster randomized trial (Aim 2). Implementation strategies will include patient and team training, actionable data provided to the teams, and adoption of new billing codes. We will assess the impact of implementation strategies using the Reach, Effectiveness, Adoption, Maintenance (RE-AIM) framework (Aim 3). Our primary outcomes will be HTN control and patient use of HBPM. Secondary outcomes will include the proportion of patients with uncontrolled BP who are seen within 60 days, establishment of team charters by teams (adoption), and financial sustainability based on a cost analyses (maintenance). We will use realist evaluation to test theoretical assumptions underlying the implementation strategies (Aim 4). This mixed-methods approach will allow us to develop transferable lessons for other settings. Our findings will advance the science on implementation of successful HTN management models and provide a roadmap towards broader implementation of TB-HBPM in primary care.