Addressing Hypertension Outcomes Using Telehealth and Population Health Managers: Adaptations and Implementation Considerations

Abstract

Purpose of Review There is a growing evidence base describing population health approaches to improve blood pressure control. We reviewed emerging trends in hypertension population health management and present implementation considerations from an intervention called Team-supported, Electronic health record-leveraged, Active Management (TEAM). By doing so, we highlight the role of population health managers, practitioners who use population level data and to proactively engage at-risk patients, in improving blood pressure control. Recent Findings Within a population health paradigm, we discuss telehealth-delivered approaches to equitably improve hypertension care delivery. Additionally, we explore implementation considerations and complementary features of team-based, telehealth-delivered, population health management. By leveraging the unique role and expertise of a population health manager as core member of team-based telehealth, health systems can implement a cost-effective and scalable intervention that addresses multi-level barriers to hypertension care delivery. Summary We describe the literature of telehealth-based population health management for patients with hypertension. Using the TEAM intervention as a case study, we then present implementation considerations and intervention adaptations to integrate a population health manager within the health care team and effectively manage hypertension for a defined patient population. We emphasize practical considerations to inform implementation, scaling, and sustainability. We highlight future research directions to advance the field and support translational efforts in diverse clinical and community contexts.

How Is Telehealth Currently Being Utilized to Help in Hypertension Management within Primary Healthcare Settings? A Scoping Review

“…A collaborative nephrologist-pharmacist telehealth clinic has also been successful in improving difficult-to-control hypertension in patients with chronic kidney disease (CKD) [105]. Telehealth-delivered approaches, such as the TEAM intervention, have been shown to improve hypertension care delivery and blood pressure control [39]. The COVID-19 pandemic has further accelerated the use of telehealth for the management of hypertension and other non-communicable diseases (NCDs) [39].…”

“…Telehealth-delivered approaches, such as the TEAM intervention, have been shown to improve hypertension care delivery and blood pressure control [39]. The COVID-19 pandemic has further accelerated the use of telehealth for the management of hypertension and other non-communicable diseases (NCDs) [39].…”

“…Telehealth interventions have been used to treat patients with hypertension, heart failure, and stroke, with most interventions employing a team-based care approach [38]. These interventions utilize the expertise of physicians, nurses, pharmacists, and other healthcare professionals to collaborate on patient decisions and provide direct care [39]. Patients using telehealth have seen significant improvements in clinical outcomes such as blood pressure control, which are comparable to patients receiving in-person care [40].…”

Implementation of NCCARE360, a Digital Statewide Closed-Loop Referral Platform to Improve Health and Social Care Coordination: Evidence from the North Carolina COVID-19 Support Services Program

“…NCCARE360 and corresponding workflows benefit from a team-based approach with defined roles and meaningful input from the patient or client [34,35]. The breadth of roles required to address social needs has substantial implications for workforce development and care team composition [36][37][38][39][40].…”

Adaptation to Telehealth of Personalized Group Visits for Late Stage Diabetic Kidney Disease

“… 27 Adaptation of more complex self-management behavioral interventions are a topic of significant interest, particularly for managing intersecting chronic conditions such as T2D, CKD, and hypertension. 28 Adapting interventions for populations at heightened cardiometabolic risk is critical to offer evidence-based telehealth programs to improve continuity of care and self-management support. The PHP group visit model was adapted to ensure educational modules, and coaching were tailored to the needs of those managing CKD, and T2D and could be delivered in a virtual ( i.e.…”