Developed and piloted an intervention to improve blood pressure (BP) and other intermediate outcomes (hemoglobin A1c, low-density lipoprotein cholesterol) of diabetes in a low-income, ethnically diverse population.
Montefiore Medical Group sites in Bronx, NY: Family Health Center
Diane McKee, MD, MS
Elizabeth A. Walker, PHD (Co-PI)
Launch: October 2006
Data Collection: August 2007- August 2009
Primary care patients with BP ≥ 140/90 on 2 visits in the past 12 months and any level of A1c were randomized to usual care (n = 24) or intervention (n = 31). Home health nurses assessed self-management and medication adherence, and they performed health behavior counseling. Participants transmitted daily BP and glucose results using simple home telemetry units to the nurse coordinator; these results were then aggregated and transmitted weekly to primary care providers to facilitate intensified treatment. After controlling for baseline levels, a significantly larger proportion of the intervention group was at goal for BP (adjusted OR = 9.3, p = .006) and A1c (AOR = 4.3, p = .049). Clinicians made more BP medication changes in the intervention group compared to the control group (8.3 vs. 3.8, approaching significance at P = .06).
We successfully developed a telephone and email-based collaboration between home health nurses and primary care clinicians to address poorly controlled hypertension in an ethnically diverse population. The intervention, combining enhanced feedback to patients and their primary care providers and individualized behavior change support by home health nurses, is effective for improving BP and glucose in this setting. An R18 intervention proposal is in development.
Program Coordinator: Giselle Campos-Dominguez, 718-430-3742, email@example.com.