Home-Based Blood Pressure Interventions for African Americans

BACKGROUND:

Home health care is a non-institutional, "diverse health care setting" that provides services to a high-risk population characterized by multiple chronic conditions and significant needs for both medical and self-care management. Home health agencies discharged approximately 7.6 million patients in 1998, of whom approximately 60 to 65% were female and 12 to 15% black (US DHHS 2000; Haupt 1998). Home health patients are clinically diverse. Individuals with conditions of the circulatory system comprise the single largest share (about 22% in 1996) (Haupt 1998), while heart failure (I-IF), diabetes, chronic obstructive pulmonary disease, and essential hypertension (HTN) are patients' most frequent primary diagnoses (Haupt & Jones 1999). Most home health patients enter care after a hospitalization and more than two-thirds are discharged to the community. Management of HTN has not been a high priority for guideline adoption or quality improvement activities in home health care (Peterson 2004), even though approximately 8% of home care patients are admitted with essential HTN as a first, second, or third diagnosis (Haupt & Jones, 1999). In the words of one clinical nurse specialist, home health nurses tend to see elevated BP readings as "a set of numbers rather than a condition to be managed," despite the fact that their patients may be at high risk of future HTN-related complications by virtue of their comorbidities and history of prior hospitalization.

Teaching patients about their conditions, promoting patient self-management, helping patients adhere to medical regimens established by their physicians, and linking them to community resources are central to the role of the home health nurse (Clemen-Stone et al. 2002). However, with the advent of a home health prospective payment system, nurses are working under heightened pressure to constrain service use and reduce time in the patient's home. This pressure, in turn, may provide a disincentive to focus on high BP management issues, particularly when HTN is a second or third diagnosis and not the primary reason for which a person has been admitted to home care. Thus home health care represents a segment of the health care system where a significant number of high-risk HTN patients are served, where HTN practice likely requires significant improvement, and where nursing personnel are uniquely positioned to mobilize their care management and patient education skills to increase the proportion of treated HTN patients who achieve adequate BP control. The underlying premise of the project is that organizational change to improve BP management and outcomes will not easily occur in home health care without new intervention models, rigorous evaluation of their impact, or efforts by opinion leaders in the clinical and research communities to disseminate information on strategies that are efficacious and cost-effective. Visiting Nurse Service of New York (VNSNY), serving over 70,000 adult patients per year, provides a prominent organizational "laboratory" for testing promising new models of care.

The study is in response to a Request for Applications released in September 2003 on "Interventions to Improve Hypertension Control Rates in African Americans."

DESIGN NARRATIVE: