Encore: Fighting Hypertension Through Community Collaboration

00:00:00:04 - 00:00:16:15
Tom Haederle
Welcome to Advancing Health. Advancing Health works to bring you podcasts that inform, inspire and enlighten. Please enjoy this encore airing of a great discussion about fighting hypertension through community collaboration.

00:00:16:17 - 00:00:42:06
Chris DeRienzo, M.D.
Hello again! I am Doctor Chris DeRienzo, the chief physician at the American Hospital Association. Joining me today is Anna Tharakan. She is the lead project manager on the closing the gap on hypertension disparities work at Duke. And Bradi Granger, who is a professor in the Duke University School of Nursing and a co-PI for that same project. Thank you both for joining us on the podcast today.

00:00:42:10 - 00:00:44:24
Chris DeRienzo, M.D.
I am so excited to get to welcome you here.

00:00:44:27 - 00:00:46:00
Anna Tharakan
Hi. Happy to be here.

00:00:46:07 - 00:00:48:00
Bradi Granger, Ph.D.
Thanks for having us today.

00:00:48:02 - 00:01:11:11
Chris DeRienzo, M.D.
Well, let's jump right in. You know, the community health needs assessments is a really broad, overview of both the assets and the needs within a community. I have known the community here in Durham, North Carolina, for nearly 25 years, when I started medical school in the early 2000s. But I'm really curious, you know, Duke Health has excelled in doing its CHNAs for a long time.

00:01:11:16 - 00:01:18:03
Chris DeRienzo, M.D.
Talk to us about how do you approach the CHNA and what kinds of things have you uncovered? Anna, we'll start with you.

00:01:18:05 - 00:01:47:06
Anna Tharakan
It's kind of kind of setting up what hypertension is present within our community. We see that despite the proven interventions that are currently present, over 50% of patients that are diagnosed with hypertension kind of have their condition controlled. And kind of specifically within Durham, we see that there's a prevalence of hypertension of almost 42%. So I think for us, those are kind of really some baseline statistics of really motivating us to kind of get out into the neighborhood and communities and reduce these hypertension disparities and improve overall population health.

00:01:47:08 - 00:02:13:18
Anna Tharakan
So kind of our approach was taking a quality improvement intervention to target these hypertension disparities via a telephone outreach program. So we partnered with the local FQHC or Federally Qualified Health Center and students based out of Duke Health to kind of deliver this telephone outreach. We aligned these functions essentially through student ambassadors, which were these students that conducted a structured telephone outreach to kind of help reach patients where they are.

00:02:13:19 - 00:02:36:21
Anna Tharakan
So over a series of 3 to 4 phone calls directly work with our patient cohort, which was around 300 patients, to help identify hypertension education. What are ways that we can help kind of work within their lifestyles - so maybe a touch hypertension care. We distributed free blood pressure cuffs. We helped them create smart goals and accountability partners. And then lastly also conducted a social needs assessment.

00:02:36:24 - 00:02:42:10
Anna Tharakan
Which was really just trying to identify what are other things that are kind of getting in the way of your hypertension and health.

00:02:42:12 - 00:02:59:18
Chris DeRienzo, M.D.
Let's pause there for a second because, wow. I mean, the level of depth that you are able to go to, is truly impressive. But bring this up, you know, to the 30,000ft view level for a moment, because I don't know how many of our listeners are familiar with the Durham community and specifically the role that Duke plays in that community.

00:02:59:19 - 00:03:11:21
Chris DeRienzo, M.D.
So can you give it just sort of the brief snapshot of when you're talking about, you know, over 40% of the Durham population? How many people are we really talking about? And when you're saying going into the community, what does that look like?

00:03:11:23 - 00:03:49:19
Bradi Granger, Ph.D.
I can pitch in here. Durham has about 300,000 people. And roughly, as Anna pointed out, we have a prevalence of hypertension of about 42 to 48% of the people in this county have hypertension. About half of those are uncontrolled or unaware. And so the third issue, I would say in Durham County, is the disparity in care that we've seen and the prevalence that the higher prevalence and the higher mortality and comorbidity that is associated with this chronic illness in the black population. Which that statistic is true throughout the South.

00:03:49:25 - 00:04:29:21
Bradi Granger, Ph.D.
And so we have a high proportion of minorities and underserved patients in Durham County. And we tend to focus on these first, as the risk in this group is much higher than the risk in the average population overall. So given that we started there, the clinics and the specific areas in the community where we could be most effective in improving overall health for the community were those underserved, like safety net clinics. And so across the county, we have our federally qualified health center, which Anna mentioned and our, my co-PI, Dr. Holly Biola, is there leading the effort there.

00:04:29:28 - 00:04:51:12
Bradi Granger, Ph.D.
And we've also worked together with the Duke Safety Net Clinic, the Duke Outpatient Clinic, as well as our broader population health clinics in the county. So though the work began at Lincoln, our federally qualified health center, we have reached out to try and scale the project across other areas in the community that represent underserved populations.

00:04:51:14 - 00:05:13:23
Chris DeRienzo, M.D.
Thank you so much for sharing that. You know, I moved to North Carolina 25 years ago, and in the other places I've lived, I never really had the level of appreciation that I have now for just how different a place like Durham County can look when you drive like eight minutes from the downtown core, because Durham, you know, with 300,000 people, there's definitely a downtown core and there's some high rises.

00:05:13:23 - 00:05:38:09
Chris DeRienzo, M.D.
And I mean, it's not, you know, like New York City's downtown, but it's definitely an inner city environment. But eight minutes away, you are in farm country. And so when you're talking about reaching a community, like you are going from a very urban feel to a very rural feel quite quickly. And so I know that community health workers have played a huge role in how you all have addressed this work through the project around hypertension.

00:05:38:12 - 00:05:47:11
Chris DeRienzo, M.D.
Tell us a little bit more about the role that you all are finding, community health workers playing and amplifying community outreach.

00:05:47:13 - 00:06:15:15
Bradi Granger, Ph.D.
We have a cohort of community health workers. The intent for that workforce is to really expand and extend the work that's done in a clinic, during a clinic visit with a primary care provider. The fact is that many of our people in the underserved area, especially, have so many social determinants, which Anna can expand on, that it's hard to fit the care that's needed within that short window of time of the visit.

00:06:15:18 - 00:06:38:21
Bradi Granger, Ph.D.
So this project has served to really engage health professions students like Anna as patient navigators to partner with these community health workers and literally give everyone more time to be able to provide the care, at the community level, that we want to do. So. So Anna can expand on exactly what that looks like.

00:06:38:23 - 00:06:59:24
Anna Tharakan
I think kind of as she pointed out, there was this huge not gap necessarily, we realized, but kind of this, this system that patients can't necessarily kind of getting the full time that they needed to just with the limitations of the system. And so I think what really community health workers, and in our case, students were able to really fill that gap was kind of being able to take that time with patients when they had it.

00:06:59:27 - 00:07:25:28
Anna Tharakan
Our first call with patients that students made was just sitting down with them being like, are you interested in kind of learning more about what hypertension means or how we can kind of implement some lifestyle changes, and can we do that on your time? I think that was just a really big portion of whether it was people that were working 2 to 3 jobs and only had availability at 8 p.m. or 9 p.m., I think that was kind of the really great gap that students could kind of fill, is kind of making sure outside clinic hours, where can we sit in and really impact and make a change.

00:07:26:01 - 00:07:54:02
nna Tharakan
And then on top of that, really kind of making it really personalized with that education that we gave them. Learning about the different things that they were kind of experiencing, what kind of struggles were specifically relevant to their lives, whether that was I'm struggling or trying to get groceries when I have to make sure to pick up my kids from preschool, or whether it's I'm taking care of two of my parents that are, kind of based in the hospital and kind of making sure that we were able to insert little pieces of advice, whether it's, hey, like, how about we try to get 30 minutes, you know, walk to your parent's house instead of,

00:07:54:04 - 00:08:05:06
Anna Tharakan
necessarily being able to drive there and really kind of instill small changes that they can make and really be their personal cheerleader and kind of instill in these small changes that can really make such a big difference in their blood pressure and hypertension.

00:08:05:09 - 00:08:22:13
Chris DeRienzo, M.D.
I love that. Wouldn't we all benefit from having a personal cheerleader, especially when fighting, you know, a condition like hypertension, which is so seemingly innocuous because it's just a number on a machine. But we know that, that years and years and years of high blood pressure take its toll on nearly every organ system in the body.

00:08:22:15 - 00:08:40:14
Chris DeRienzo, M.D.
And again, being good project leads, I imagine you all are measuring countless kinds of metrics through this work. What is, one measurable impact that you can tell us about through this engagement of community health workers and really extending their reach, and not only into patients homes but into community based settings as well?

00:08:40:16 - 00:08:59:21
Anna Tharakan
I think the big one was just the impact that we had on their blood pressure. And then also just self-management. I think within our intervention this past year, we saw a average drop in the systolic blood pressure of those that participated of over 15mg mercury, which is just a really huge kind of drop when considering the intervention that took place.

00:08:59:23 - 00:09:18:29
Anna Tharakan
And I think another big one was this idea of self monitoring, kind of bringing the power to the patient, kind of being able to track with the free blood pressure cuffs that they were able to be provided, as well as a social needs assessment was kind of really putting that power of health back in their hands and showing that community health intervention led can produce really meaningful clinical outcomes.

00:09:19:01 - 00:09:21:19
Chris DeRienzo, M.D.
Spectacular. Bradi, anything you would add?

00:09:21:21 - 00:09:54:26
Bradi Granger, Ph.D.
The one thing I would add to that is the idea of the system integration that this project brings, whereby, to your point, hypertension really is a chronic illness, that the long term outcome is what we're after: reduction in stroke, reduction in chronic kidney disease and reduction in cardiovascular events. But those things happen so far from, you know, today's single measurement or even a couple of years worth of measurements of high blood pressure in an office visit, which is often mistakenly elevated anyway.

00:09:54:28 - 00:10:25:20
Bradi Granger, Ph.D.
So our real achievement, I feel like in addition to what Anna said about bringing the power to the patient to set their goals and really be able to be aware and to be responsible for changes and improvements in their health. We also really are trying to effectively connect a patient to the primary care provider team, including the community health worker and the community business organizations that help us serve patients outside of the formal system of health care delivery.

00:10:25:23 - 00:11:15:21
Bradi Granger, Ph.D.
These groups provide food, transportation, assistance with housing insecurity and all the things that are real barriers for patients managing long term hypertension. So solving for those things and tracking it as we have and making sure there's a closed loop on the referrals that happen, allows us to really measure the impact of this kind of project on some of our really important community outcomes, but also the policy implications for this project, which we're working on now with our North Carolina Department of Health and Human Services, and trying to make sure that the opportunity for us to expand healthy opportunities pilots from our Medicaid expansion initiative, trying to make sure that we have the evidence and

00:11:15:21 - 00:11:22:13
Bradi Granger, Ph.D.
the measurable outcomes to support new policies for expansion of those kinds of efforts in the community.

00:11:22:15 - 00:11:52:00
Chris DeRienzo, M.D.
Well, you all have certainly covered the waterfront. I mean, clearly, it takes it takes a team. And you've been able to connect to not just the acute care clinical team, but, the patient's family, community, teams all together in this web in supporting patients. And I'm curious. We've only got a minute or two left. If you had to give one piece of advice for health care team members in a community right now listening to this podcast who are just coming away from hearing your story and saying, I got to go do this tomorrow.

00:11:52:03 - 00:11:57:12
Chris DeRienzo, M.D.
What would your one piece of guidance be as they're preparing to take their first step?

00:11:57:15 - 00:12:08:15
Bradi Granger, Ph.D.
Our guidance would be communicate with your primary health care provider and let them know you're interested in joining our team as a patient expert in the hypertension Management program.

00:12:08:18 - 00:12:17:19
Chris DeRienzo, M.D.
Outstanding. Anna, what if you were giving advice to a hospital who is hearing the story? And they said, I want to be just like this project that they're doing, I do.

00:12:17:22 - 00:12:32:15
Anna Tharakan
I think it's just showing that it's possible to kind of get intervention like this off the ground, and it really can make a real big difference in patients lives. And so kind of putting a focus on community health workers and kind of connecting back to that primary care, as Dr. Granger said, is a really important component.

00:12:32:17 - 00:12:50:25
Chris DeRienzo, M.D.
You have done tremendous work. Obviously connecting all the way back to the community health needs assessment. What it lifts it up, how you connect that to a project, building in the approach that brings community health workers into the fold, and then obviously bringing patients and family members into the fold with you. We could not wish you more luck in the work that you're doing.

00:12:50:25 - 00:12:55:27
Chris DeRienzo, M.D.
And again, couldn't think of a better story to tell. Any closing thoughts before we say goodbye?

00:12:56:00 - 00:13:03:26
Bradi Granger, Ph.D.
I think thanks for your support and for the dissemination of efforts like this and the impact it has on our community. Thank you.

00:13:03:28 - 00:13:07:09
Chris DeRienzo, M.D.
Couldn't say it better myself. Thank you both so much.

00:13:07:12 - 00:13:15:23
Tom Haederle
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