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

项目摘要/摘要：由于存在障碍，黑人的高血压(HTN)控制不够理想 患者、卫生系统、提供者和社区层面的护理。虽然护理案的功效 管理(NCM)和家庭血压监测(HBPM)是经过充分验证的；这些策略没有 解决社区层面的障碍(不稳定的住房、交通)，以充分控制HTN，从而限制 他们对黑人的影响。将社区卫生工作者(CHWS)融入初级保健以帮助患者 对于遇到社区障碍的患者，导航社区资源对控制HTN是有效的。 尽管它们有效，但这些多层次循证干预措施(NCM、HBPM和 在现实世界的初级保健实践中，大多数少数族裔患者 接受护理，是次优的。这项建议利用了实践促进(PF)-一个理论上合理的和 评估NCM、HBPM和CHW的执行情况的可持续实施战略 综合的社区-诊所联系模式[实践支持和社区参与(PACE)] 在黑人中解决患者、医生、卫生系统和社区层面的HTN控制障碍。我们会 在纽约大学朗格尼健康中心的20个初级诊所网络中测试PACE的实施情况 纽约市，与已建立的社区-诊所-学术咨询委员会和HealthFirst(纽约市的 最大的医疗补助支付者)。实践协调员将协助实践将NCM和HBPM整合到临床中 6个月的工作流程，之后重新评估患者的血压控制状态；对于那些留下来的人 在不受控制的情况下，促进者将协助实践制定将CHW添加到护理中的流程 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HTN的团队 控制力。NCM包括家庭血压远程监护、行为咨询和药物调整/滴定 由训练有素的护士。训练有素的社区卫生工作者与护士合作，加强护理协调，并提供 健康指导和实践与社区资源之间的双向转介。我们将进行 拟议的研究分两个阶段进行：1)UG3阶段，将使用以社区为基础的参与性原则 研究和实施研究的综合框架，以开发特定于上下文的PF 战略和；2)UH3实施阶段，将使用普罗科特的实施成果框架 在阶梯楔形群集中评估500名未控制的黑人患者的20项初级保健做法的RCT HTN，PF策略对PACE的临床和成本-效果的影响。我们还将研究领养情况 以及实施保真度作为可能的机制，可以解释PF对BP控制的影响。主要 结果是从基线到18个月的血压控制。次要结果是PACE的成本效益。这个 这项研究的发现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，以管理少数民族人群中的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.