Latest / Becker’s Healthcare Podcast / Community and Clinical Workflow Insights for Hypertension Care: Part 2
Transcript
- 0:00- Thanks so much for tuning in to the
- 0:01- Becker's Healthcare podcast.
- 0:03- This is the second episode of a three
- 0:05- part series produced in partnership with the American
- 0:08- Heart Association,
- 0:09- community and clinical workflow insights for hypertension care.
- 0:13- In this episode, we're joined by Gracianne Garces,
- 0:17- chief strategy and external affairs officer of the
- 0:19- Tejano Center for Community Concerns,
- 0:22- Susan Bolin, manager of nursing operations at Avenue
- 0:26- three sixty health and wellness,
- 0:28- and Erin Sims,
- 0:29- LVN and hypertension nurse champion at Avenue three
- 0:33- sixty health and wellness.
- 0:35- Thanks for listening, and be sure to stay
- 0:37- tuned for our third and final episode.
- 0:40- So good morning, everyone. I'm so grateful for
- 0:42- the opportunity to be here with you today.
- 0:45- Before anything else, I do wanna extend our
- 0:48- sincere gratitude on behalf of Tejano Center to
- 0:51- the American Heart Association
- 0:52- for their thoughtful and intentional partnership.
- 0:56- Your commitment to walking alongside community organizations like
- 1:00- the Hanoi Center
- 1:01- truly does reflect a shared belief that every
- 1:04- neighbor
- 1:05- deserves the opportunity
- 1:07- to lead their healthiest life.
- 1:10- What makes this specific partnership or what has
- 1:13- made it and continues to make it special,
- 1:16- and especially meaningful is that it goes beyond
- 1:20- the funding and the programmatic
- 1:22- engine that we have established together.
- 1:24- It is rooted in listening to community needs,
- 1:28- in building trust,
- 1:30- and in creating sustainable pathways towards healthier futures
- 1:34- for all of our neighbors.
- 1:36- We are incredibly proud of what of what
- 1:39- we have been able to build together and
- 1:42- excited to continue deepening
- 1:44- that impact.
- 1:47- To better understand why this work matters, I
- 1:50- first wanna share a little bit more about
- 1:52- who Tejano Center is
- 1:54- and the communities
- 1:55- that we live to serve every single day.
- 2:00- Tejano Center is a community centered
- 2:02- organization
- 2:04- dedicated to empowering families and transforming communities
- 2:08- through education,
- 2:09- social services,
- 2:11- housing stability,
- 2:13- and wellness initiatives.
- 2:15- For decades, our work has focused on walking
- 2:18- alongside families
- 2:20- holistically,
- 2:21- recognizing
- 2:22- that long term opportunity
- 2:25- and stability require support across multiple areas of
- 2:29- life.
- 2:30- Across all of our programs and services,
- 2:32- Tejano Center serves more than 46,000
- 2:35- individuals
- 2:36- and families
- 2:37- annually
- 2:38- throughout the Greater Houston area and Brownsville, Texas.
- 2:43- That reach
- 2:44- reflects the scale of community need, but most
- 2:48- importantly,
- 2:49- it demonstrates
- 2:50- the trust that has been built within the
- 2:52- neighborhoods that we have served since 1992.
- 2:56- At the Hanoi Center, we understand that community
- 2:59- outcomes are deeply connected to everyday realities.
- 3:03- Access to nutritious food, preventative care, education,
- 3:07- stable housing,
- 3:08- trusted support systems, all influence a person's ability
- 3:12- to live a healthy life.
- 3:14- That understanding
- 3:15- has led us to strengthen our health pillar,
- 3:19- an area of work focused on improving community
- 3:22- wellness through prevention,
- 3:24- education,
- 3:25- access, and partnership.
- 3:27- One of the strongest
- 3:28- examples of that work
- 3:30- is LaTientita.
- 3:32- LaTientita
- 3:33- began
- 3:34- with a simple but important question.
- 3:37- How do we create a model
- 3:40- that addresses food insecurity
- 3:42- while also creating healthier futures for families,
- 3:46- essentially addressing this issue systemically?
- 3:50- So what is Latiandita?
- 3:52- Latiandita was created
- 3:54- as a culturally responsive,
- 3:56- dignity centered wellness model
- 3:59- designed to address food insecurity
- 4:01- while advancing
- 4:02- long term health outcomes.
- 4:05- But more than anything,
- 4:06- La Fiendita was created with the belief that
- 4:09- families,
- 4:10- regardless of where they come from, the challenges
- 4:12- that they're leading,
- 4:14- the struggles that they're facing,
- 4:16- all deserve access to healthy food in a
- 4:18- way that feels empowering,
- 4:21- welcoming, and most importantly, that is always rooted
- 4:24- in the preservation
- 4:26- of their dignity.
- 4:27- We wanted to move beyond the traditional food
- 4:30- pantry model
- 4:31- and instead create a community centered space where
- 4:34- families could access
- 4:36- nutritious food, but also
- 4:38- education,
- 4:39- wellness resources, and trusted support.
- 4:43- In 2025
- 4:44- alone, LaTiendita
- 4:45- served more than 26,000
- 4:47- individuals and families.
- 4:49- More than half of that is representative
- 4:52- of our organization's overall impact.
- 4:55- Families who visit La Tendita
- 4:57- gain access to healthy quality foods, nutritious education,
- 5:01- health screenings and awareness tools,
- 5:04- connections to wrap around services,
- 5:06- trusted guidance and support.
- 5:08- This work would not be possible without intentional
- 5:11- partnerships.
- 5:13- The American Heart Association
- 5:15- has been with us from the very beginning
- 5:18- and has been there with us every step
- 5:20- of the way as we have expanded our
- 5:22- vision around prevention, education,
- 5:24- and hypertension
- 5:26- awareness.
- 5:27- The Houston Food Bank has also been an
- 5:29- essential partner in helping ensure families have reliable
- 5:33- access to that nutritious food.
- 5:35- Together, these partnerships have allowed us to build
- 5:38- a model that address both immediate needs and
- 5:41- long term wellness.
- 5:42- What makes
- 5:44- most powerful is that it meets families where
- 5:46- they are and creates opportunities for healthier living
- 5:50- spaces
- 5:51- where trust already exists.
- 5:54- As we continue growing Latin Dita, we realize
- 5:58- food access alone was not enough if we
- 6:00- truly wanted to impact
- 6:02- hypertension
- 6:03- and chronic disease outcomes.
- 6:06- As we know, hypertension is often called a
- 6:09- silent condition because many individuals do not realize
- 6:12- that they are at risk until serious health
- 6:14- complications or complications occur.
- 6:16- Recently,
- 6:17- I went in for my wellness check and
- 6:19- shouldn't have been surprised, but was, as I'm
- 6:22- sure we often are, at how elevated my
- 6:25- numbers were. I had no symptoms. I had
- 6:27- absolutely no indicators.
- 6:29- But I was fortunate enough to be sitting
- 6:31- with my physician, and we immediately started addressing
- 6:34- the issue.
- 6:35- Unfortunately, this is not ideal for those whom
- 6:38- frequent.
- 6:39- In the communities we serve, barriers such as
- 6:42- limited health care access,
- 6:44- food insecurity,
- 6:45- transportation,
- 6:46- challenges, and lack of preventative education can make
- 6:49- early intervention
- 6:51- even more difficult.
- 6:53- That is
- 6:54- where plays an important role and why this
- 6:56- hypertension initiative was so important.
- 6:59- We are uniquely positioned to engage neighbors in
- 7:03- trusted,
- 7:03- familiar environments
- 7:05- where conversations
- 7:06- around health can happen naturally.
- 7:09- Through our nutrition education efforts, families learn how
- 7:13- to shop intentionally,
- 7:15- how to understand
- 7:17- nutrition labels,
- 7:18- how to prepare healthier versions
- 7:20- of culturally familiar meals,
- 7:23- and how to build
- 7:24- sustainable
- 7:25- habits at home.
- 7:27- And now thanks to this hypertension
- 7:30- initiative
- 7:32- and the hypertension awareness kiosk specifically,
- 7:35- neighbors are empowered
- 7:37- to monitor their blood pressure,
- 7:39- learn about hypertension risks and what they mean,
- 7:43- to normalize proactive health monitoring,
- 7:46- and how to begin conversations
- 7:49- about prevention and care.
- 7:51- Our role is not to replace health care
- 7:54- providers,
- 7:54- but it is to help bridge the gap
- 7:56- between community and care by increasing awareness, reducing
- 8:01- barriers,
- 8:01- and helping families take that first step toward
- 8:04- healthier living.
- 8:06- Because these services are delivered in trusted community
- 8:09- spaces,
- 8:10- neighbors are often
- 8:12- more willing to engage,
- 8:14- more willing to ask questions,
- 8:16- and have more courage to seek support.
- 8:20- But as I'm sure we have all come
- 8:22- to understand in our respective roles,
- 8:24- creating healthier lives requires more than one service
- 8:28- and definitely more than one organization
- 8:31- as a testament to everyone that's here today.
- 8:33- It requires an ecosystem of care working together
- 8:38- holistically.
- 8:39- At Tejano Center, we believe true community wellness
- 8:43- must be approached holistically.
- 8:45- Families cannot fully focus on their health when
- 8:48- they are simultaneously
- 8:49- navigating food insecurity and all of the other
- 8:52- challenges that they face.
- 8:53- That is why Latiendita functions as part of
- 8:56- a broader ecosystem of care through this initiative.
- 8:59- Through coordinated partnerships and wrap around support,
- 9:03- we've helped chart pathways towards healthier lives.
- 9:06- The ecosystem has included our community health workers
- 9:09- who provide trusted guidance, resource navigation,
- 9:13- and follow-up support,
- 9:15- nutrition education and wellness resources,
- 9:18- reliable access to healthy foods, family support programs,
- 9:22- and wrap around services
- 9:23- to help entire households thrive,
- 9:26- prevention and awareness partnerships
- 9:28- with organizations
- 9:30- like the American Heart Association
- 9:32- and everyone that's on this webinar now.
- 9:35- And, of course, health care providers and clinics.
- 9:38- This model allows us to meet immediate needs
- 9:41- while also helping families move toward long term
- 9:44- wellness and stability.
- 9:46- Most importantly, it reinforces
- 9:48- that health equity work is strongest when it
- 9:51- is collaborative,
- 9:52- culturally responsive,
- 9:54- and relationship driven.
- 9:56- One of the most impactful
- 9:58- outcomes that we have seen through this collaboration
- 10:00- has been the creation
- 10:02- of a stronger community referral
- 10:05- ecosystem.
- 10:06- Through our strong partnership with the Heart Association,
- 10:09- we've been able to strengthen and expand a
- 10:12- community referral ecosystem that moves beyond the awareness
- 10:15- alone.
- 10:16- Together, we recognize that education and screens are
- 10:19- important, but true impact happens when neighbors are
- 10:22- successfully connected to ongoing care.
- 10:25- This partnership has self ship helped shift our
- 10:28- work from awareness
- 10:30- to action to care.
- 10:32- Through this ecosystem,
- 10:34- neighbors identified as at risk or in need
- 10:37- of support
- 10:38- can be connected to health care providers,
- 10:40- health clinics,
- 10:41- screenings, and continued care management.
- 10:44- We're incredibly grateful to collaborate with several health
- 10:47- care and community partners
- 10:49- who help make these connections possible.
- 10:52- What makes this approach especially impactful is that
- 10:54- families are not expected
- 10:56- to navigate what are already complex health care
- 10:59- systems alone.
- 11:01- Instead,
- 11:01- they're supported through trusted relationships and intentional
- 11:06- warm referrals
- 11:07- that help reduce barriers to health.
- 11:10- This is helping us create a more connected
- 11:13- and community centered pathway toward prevention
- 11:16- and long term health management.
- 11:18- And we're already seeing impactful impact from these
- 11:21- connections
- 11:22- and referrals
- 11:24- across our communities.
- 11:26- Since launching the hypertension initiative with the American
- 11:29- Heart Association in 2024,
- 11:31- we've continued seeing meaningful engagement
- 11:34- and impact across our Houston, Broadway,
- 11:37- and Pasadena locations.
- 11:39- We see more than numbers in the data.
- 11:42- We see neighbors who are taking proactive steps
- 11:44- towards healthier lives and families who are being
- 11:47- connected to resources and care they may otherwise
- 11:51- not have accessed.
- 11:53- One of the most significant outcomes has been
- 11:55- the growing number of referrals and successful connections
- 11:58- to health care providers
- 11:59- and clinics.
- 12:01- This is especially
- 12:02- key because these efforts
- 12:04- are currently taking place in only two of
- 12:07- three of our largest La Quintita sites.
- 12:10- Even with just those two locations,
- 12:13- we are already seeing the power of trusted
- 12:15- community based referral pathways.
- 12:18- The impact
- 12:19- reinforces that when prevention education,
- 12:22- trusted relationships, and health care partnerships work together,
- 12:26- we can create that strong long term
- 12:29- outcome for the communities we serve.
- 12:32- As we continue
- 12:33- expanding this work, we are incredibly grateful for
- 12:36- the partnerships helping make this vision possible.
- 12:40- At its core, the hypertension initiative is about
- 12:43- so much more than hypertension
- 12:45- while building healthier communities through dignity,
- 12:48- prevention,
- 12:49- trust, and partnership.
- 12:50- Latiandita
- 12:51- has demonstrated what is possible
- 12:53- when organizations
- 12:55- come together to address both immediate needs and
- 12:58- long term health outcomes.
- 13:00- We're incredibly grateful for the partnership and shared
- 13:03- commitment that has made this work possible.
- 13:06- Together, we're helping families move beyond crisis response
- 13:10- towards long term wellness and stability.
- 13:12- Thank you again for the partnership, for your
- 13:14- support, and for your belief in community centered
- 13:17- health solutions.
- 13:19- And I am more than happy to talk
- 13:21- about the work that we're doing, the model
- 13:23- that we take through La Tiandita,
- 13:25- and specifically
- 13:26- the very intentional ecosystem
- 13:28- of referral partners that we've established.
- 13:32- Well, almost good afternoon. Hi. I'm Susan Bolin.
- 13:35- I'm the manager of nursing operations for Avenue
- 13:38- three sixty, which is an FQHC
- 13:41- agency. We have six clinics surrounding Houston, and
- 13:43- we actually have one hospice.
- 13:45- I just would like to thank all the
- 13:47- previous presenters on this collaborative for sharing their
- 13:50- informative information about what they're doing in their
- 13:53- places in different parts of the country. And
- 13:55- it's I think it's really important, and it's
- 13:57- interesting how we are all trying to achieve
- 13:59- the goal of getting people in the community
- 14:01- and our patients to know their numbers because
- 14:04- we all know the negative effects if they
- 14:06- don't.
- 14:07- As you can see, there are many types
- 14:09- of ways to develop projects and to serve
- 14:11- our communities.
- 14:13- And this could not have been possible without
- 14:15- the continuous
- 14:16- support of the American Heart Association locally with
- 14:20- Veronica Sanchez, thank you very much again, and
- 14:22- the,
- 14:23- team in Chicago.
- 14:25- They were always there. We needed anything, whether
- 14:27- it was literature for our patients or we
- 14:29- had questions about things, and then the collaborative
- 14:31- meetings that we would have throughout the year.
- 14:33- It really has been an enjoyable project for
- 14:36- me, and I think the other people in
- 14:37- my team feel the same way.
- 14:39- So many of our values and missions basically
- 14:42- are surrounded by providing high quality care to
- 14:45- our patients, and one of our vision statements
- 14:47- is that we would like to be the
- 14:49- provider of choice for our patients.
- 14:51- I don't know if many of you know
- 14:52- what an FQHC
- 14:54- is. I didn't before I came to Houston.
- 14:56- I came from an acute care hospital, so
- 14:58- I learned that it was a federally qualified
- 15:00- health center,
- 15:01- which is something that we basically are we
- 15:05- work off of grants. And so everything that
- 15:07- we do down to the pencils that we
- 15:08- use on our desks
- 15:09- are funded by grant money. We are one
- 15:12- of 71 FQHCs in Texas and one of
- 15:15- eight in the greater Houston area.
- 15:17- We offer primary care, HIV, STD services, behavioral
- 15:21- health, dental, and pediatrics
- 15:23- with a focus on inclusive care for LGBTQ
- 15:27- and those communities.
- 15:28- We're also one of the only FQs in
- 15:30- Houston to have a hospice.
- 15:33- We use a sliding fee scale. We accept
- 15:35- Medicaid, Medicare, and many other private plans.
- 15:39- The collaborative. We are really honored to be,
- 15:42- we applied and we got selected to participate
- 15:45- in this three year project, and it's been
- 15:47- a really great experience.
- 15:49- We've met a lot of people at conferences
- 15:51- and on our collab meetings from Buffalo, Columbus
- 15:54- and from Houston, and it's been wonderful because
- 15:56- we have learned from each other. We've been
- 15:58- talking about our successes and our challenges, and
- 16:00- I really think that has been instrumental
- 16:02- in helping us get through all this and
- 16:04- develop our projects.
- 16:06- Avenue 360, we serve about 12,000 people every
- 16:09- year. And so out of those, we have
- 16:11- about two thousand people that have hypertension. About
- 16:13- half of those are controlled. So the goal
- 16:15- of our project was to help get more
- 16:17- of those people under control and to close
- 16:19- our care gaps.
- 16:21- So this is the first slide. I'm gonna
- 16:23- kinda take you down into the the basement
- 16:25- workroom of our group because for a lot
- 16:27- of us, including myself, this was the first
- 16:29- grant that we've all worked on where we
- 16:31- really had to build it and see what
- 16:33- we could do with it. So I called
- 16:34- the launch, and this is one of our
- 16:36- first slides. This was actually a local meeting
- 16:38- that we had in Houston, and we were
- 16:40- invited to a luncheon where we met our
- 16:42- other Houston collaborators. So we had the nurse
- 16:44- champion at the time. It was me, a
- 16:45- dietitian.
- 16:46- We had a provider champion. We had several
- 16:49- bilingual
- 16:50- CMAs on the frontline for support, quality social
- 16:52- work, our LVN staff, and a DNP student,
- 16:55- which was instrumental
- 16:57- a little bit later on into this project
- 16:59- as I will show you.
- 17:01- So there was a lot of work. Even
- 17:03- though we we got accepted, we were very
- 17:04- happy to be doing this. It was, as
- 17:06- many of you know,
- 17:08- who started this, it was you know, we
- 17:09- worked for a couple months, many meetings trying
- 17:11- to figure out how we were gonna approach
- 17:12- this. And so we had run data. We
- 17:15- had twenty two hundred patients with the diagnosis
- 17:17- of essential hypertension.
- 17:18- The team, we divvy up the list. We
- 17:20- made our calls, and we came down to
- 17:21- a number of 30 patients who were interested
- 17:23- and committed to join our initiative.
- 17:26- We also had our frontline who kind of
- 17:27- would determine we made these calls. Are these
- 17:29- people gonna stick with the program? They're saying
- 17:31- yes, but are they really gonna stick with
- 17:32- it for, our pro our cohorts for three
- 17:34- months in nature? So the grant funds that
- 17:37- we received were wonderful because we were able
- 17:39- to buy our blood pressure monitoring kits. We're
- 17:41- able to give them goodie bags. We're able
- 17:43- to give them grocery store incentives if they
- 17:45- stayed in the program each month and did
- 17:47- what they were supposed to do by attending
- 17:48- meetings and meeting with our provider and our
- 17:50- dietitians.
- 17:51- And it also helped with ride assistance because
- 17:53- that is what transportation is one of the
- 17:55- big barriers that we do have in our
- 17:56- area.
- 17:57- One of our biggest challenges probably was, and
- 18:00- our DMP and student was instrumental in this.
- 18:02- She basically did the dive and the footwork.
- 18:04- We would have a very difficult time finding
- 18:06- a home blood pressure monitor that connected with
- 18:08- our EHR.
- 18:10- And we do use Epic, but because of
- 18:12- the type of Epic that we have, we
- 18:15- were unable to find one. So that was
- 18:16- probably our biggest challenge. Then we had a
- 18:18- launch in how are we going to get
- 18:20- the data from the patients
- 18:22- and be able to record to,
- 18:24- be involved in this.
- 18:25- Let's see what else we did have some
- 18:26- luncheons. We had some cooking classes. We had
- 18:28- exercise classes. We have people from the community
- 18:31- come and talk. We did have if you
- 18:33- were in the program, you would automatically be
- 18:35- free enrolled into the FoodRx program, which other
- 18:37- people on this call have talked about. And
- 18:39- that was basically gonna supply our patients with
- 18:41- 30 pounds of fresh produce
- 18:43- every week.
- 18:45- And I don't think a lot of people
- 18:46- realize that. And so they were pretty excited
- 18:48- to have that done. But as many of
- 18:51- you know, there were bumps along the way.
- 18:53- We got through it. Our first cohort was
- 18:55- very in person,
- 18:56- and we had many challenges with that. People
- 18:58- would cancel. They couldn't get there. They had
- 19:00- babysitting issues.
- 19:01- Work was involved.
- 19:03- And so I basically this slide, the fun,
- 19:06- the work, the fun, the work. So we
- 19:08- did a lot of things. We tried to
- 19:09- make it fun. I tried to make it
- 19:11- fun for our group. We tried to get
- 19:12- our clinics involved because if you don't have
- 19:14- buy in from your frontline staff and your
- 19:16- providers, you're not gonna have a successful program
- 19:18- because nobody knows what you're doing. So we
- 19:20- had a lot of communication
- 19:22- with all these groups talking about it, going
- 19:24- to their individualized staff meetings,
- 19:26- and I think that helped to because when
- 19:28- you have people who know what you're doing,
- 19:30- then you get buy in and you can
- 19:32- make your program more successful.
- 19:34- So here's one of the groups we started
- 19:37- receiving some of our awards for our participation
- 19:39- is from the
- 19:40- And so that's always a little bit of
- 19:42- gas for for the tank and kept us
- 19:44- going,
- 19:45- and it was fun.
- 19:47- Then the challenges, as I said, we had
- 19:48- a hard time finding a blood pressure machine
- 19:50- that connected with our EMR,
- 19:53- transportation issues, as I mentioned, people not able
- 19:56- to come to the meetings.
- 19:57- And then right. A little big thing was
- 19:59- a lot of our, clients, our patients are
- 20:01- not tech savvy. So to say, oh, sign
- 20:04- up for MyChart or to try to set
- 20:05- up a Zoom meeting, it was a lot,
- 20:07- and these were some of the the barriers
- 20:09- and the challenges that we met. But we
- 20:11- kept trying to roll it around. So then
- 20:13- our DMP student, she had to write her
- 20:15- thesis. So she had to come up with
- 20:17- a thesis project,
- 20:18- and so we did a pivot.
- 20:20- So from, like, cohort one and two, they
- 20:22- were a little but in three and four,
- 20:24- we became totally remote.
- 20:26- We have a new champion
- 20:27- which joined the team, and she had the
- 20:29- magic touch to be able to make that
- 20:31- final phone call to get people enrolled and
- 20:33- scheduled to engage the patients,
- 20:35- keep them on track, have them send in
- 20:37- the readings, and do all that stuff. We
- 20:39- continue with our gift cards. Our EHR team
- 20:42- was really great. We developed a quick referral
- 20:44- system link for the providers. So if they
- 20:46- had a patient that had high central hypertension
- 20:48- diagnosis, they could send the referral with a
- 20:50- click of a button and get it to
- 20:52- our group, and we could give them a
- 20:53- call. Then we had nursing and our DMP
- 20:55- students, as I said,
- 20:57- getting to all the meetings and continuously
- 20:59- looking for people support for this,
- 21:02- hypertension
- 21:02- project.
- 21:03- So the DNP student, we had to help
- 21:05- her develop this thesis that she had. So
- 21:07- we we kept refocusing,
- 21:09- and we went down a different path. And,
- 21:11- basically, what she ended up picking and with
- 21:13- our help was she calls it a personalized
- 21:16- coaching program to improve hypertension management.
- 21:20- And I think that
- 21:21- with her input, because she was kind of
- 21:23- we've called her our our student of the
- 21:25- operations
- 21:26- because she was looking stuff up. She was
- 21:28- doing research, what works out there, what has
- 21:31- shown to work within the last five years.
- 21:33- So she basically gave us articles to read.
- 21:36- So I can say part of our project,
- 21:37- it was really evidence based.
- 21:39- So she we have this two pronged approach.
- 21:41- It was the weekly phone calls, which was
- 21:43- reaching out to the patients, giving the personal
- 21:45- touch, couldn't leave voice mails. We had to
- 21:47- actually get in touch with the patients. If
- 21:49- we weren't getting the readings back, we had
- 21:50- to get them somehow. And then we tried
- 21:52- to set up Zoom meetings. I'll tell you
- 21:54- right now, the Zoom meeting was a big
- 21:55- flop.
- 21:56- Patients couldn't do it. They couldn't figure it
- 21:58- out.
- 21:59- We'd have, like, one patient come, and we'd
- 22:01- have to go through this whole spiel just
- 22:03- because we did because we said we were
- 22:05- gonna do it. So that was one of
- 22:07- the cohorts.
- 22:08- And then we had developed our, SMART goals,
- 22:11- and as you can see, all these things
- 22:13- that I just talked about. So we kinda
- 22:15- got a little formalized because of our DNP
- 22:17- students. So it was kinda fun, but she
- 22:19- was great. And she was just as passionate
- 22:21- and energized as we were to do this
- 22:23- to help our patients in the community. She
- 22:25- did come to the clinic. She helped us
- 22:27- make phone calls. She was going to meetings.
- 22:29- So after her idea, we just went totally
- 22:32- remote. And so three and four was remote,
- 22:35- and then we start to see some success.
- 22:37- So this is just a slide. We I
- 22:39- don't know how many of you out there
- 22:40- use a Zara. It's a quality
- 22:42- reporting tool. It's not like Epic. You can't
- 22:44- input anything, but information from Epic trans
- 22:48- transfers over to Azara. So I'm just gonna
- 22:50- go back a year.
- 22:52- So in this, this slide is basically telling
- 22:54- you that we have twenty two, roughly twenty
- 22:57- two hundred patients with essential hypertension diagnosis.
- 23:00- Eleven hundred of them are under control.
- 23:03- Ten, about a thousand of them are not,
- 23:05- and there's two hundred patients that we need
- 23:07- to reach to get under control to meet
- 23:09- the goal in Azar of sixty percent. So
- 23:12- you can see how we started out kind
- 23:13- of in the low fifties. And then last
- 23:15- fall, we had a really good group. I
- 23:17- think it was about 19 patients,
- 23:19- and, we had our nurse champion, Erin, come
- 23:21- on. And I think the combination of all
- 23:23- these things that worked, and we actually got
- 23:25- up to, like, fifty five percent, which we
- 23:27- were pretty happy about. And now you can
- 23:29- see we've kinda trailed off a little bit,
- 23:31- but we seem to maintain that. But we're
- 23:33- still doing more work.
- 23:35- And, probably the biggest thing of any project
- 23:37- is to make sure that the program that
- 23:38- you build
- 23:40- is gonna be sustainable.
- 23:41- And I feel now and I think the
- 23:43- team feels that we have it. We have
- 23:45- it figured out. It took us a couple
- 23:46- of years,
- 23:47- but we know what we need to do
- 23:49- now
- 23:50- to, to get the referrals going, to make
- 23:52- sure that we're we're talking with our patients,
- 23:54- supporting them. If they have any questions, they
- 23:56- know they can reach out to the nursing
- 23:58- team. And then the biggest thing is to
- 24:00- have people in your organization
- 24:01- have that buy in from your stakeholders.
- 24:04- Nursing's involved. We have the hit team involved.
- 24:06- All the providers are are engaged, which is
- 24:08- wonderful.
- 24:09- Social work, dietary, and, of course, our community
- 24:12- partners because they did help us with some
- 24:13- of our presentations.
- 24:15- So at this time,
- 24:17- I would like to introduce Erin Sims who
- 24:19- is our hypertension champion for this project, and
- 24:22- I'd like her to share a few words
- 24:23- of why she thinks it has been successful
- 24:25- up till now.
- 24:27- Erin. Hi. Good morning, everyone. My name is
- 24:28- Erin Sims. I'm the nurse with Avenue three
- 24:31- sixty Midtown,
- 24:32- and I'm also the, as Susan likes to
- 24:35- call me, the nurse champion for the AHA
- 24:38- hypertension program.
- 24:40- So for the last two years, it's been
- 24:43- positive, and it's been a positive experience,
- 24:45- not only for the participants, but for our
- 24:47- team as well. I really think going fully
- 24:50- remote was a game changer. For the participants,
- 24:53- it's more engagement with them. We offer a
- 24:56- televisit
- 24:57- once a month with our AAH champion provider,
- 25:01- and there is also a option if you
- 25:02- wanna do an in person visit.
- 25:04- The participants are eager to submit their blood
- 25:07- pressure readings.
- 25:08- I'm available to discuss any concerns that someone
- 25:11- may have or answer any questions or even
- 25:14- give them a text or call
- 25:16- with, we have
- 25:18- a a app. It's called intermediate
- 25:20- unite app, and it's all
- 25:22- it's all in HIPAA compliance.
- 25:24- So, you know, if I see a reading
- 25:25- that's off the wall or reading that maybe
- 25:28- has elevated over the last two weeks, I'll
- 25:31- give the participants a call.
- 25:34- And they like that personal interaction.
- 25:36- So like I said, I'm available to discuss
- 25:38- any concerns that someone may have and answer
- 25:41- any and all questions.
- 25:43- The incentives that are offered, they help as
- 25:45- well.
- 25:46- This has been such a rewarding program for
- 25:48- both our A H team and the participants.
- 25:51- We are so happy to have worked with
- 25:53- the American Heart Associations,
- 25:55- and we look forward to continue to working
- 25:57- with them in the future.
- 25:59- Thank you. Thanks, Erin.
- 26:02- A big thank you to our sponsor for
- 26:03- the series, the American Heart Association.
- 26:06- You can find more Becker's Healthcare podcast anytime
- 26:09- by visiting our podcast page at beccarshospitalreview.com.
- 26:13- Thanks again for joining us, and stay tuned
- 26:15- for the third and final episode of this
- 26:17- series, community and clinical workflow insights for hypertension
- 26:21- care. Thank you.