by Raj Padwal MD MSc FRCP(C), Debra McGrath MSN FNP, Liliane Offredo-Zeik (Sano Health)
Self-Monitored Blood Pressure (SMBP) is increasingly viewed as the preferred method of assessing and monitoring patients with hypertension, a condition that affects one in two Americans. An SMBP program involves creating a structured plan to identify, onboard, treat, and follow-up with patients with uncontrolled blood pressure (BP) using SMBP, in order to improve health outcomes, reduce complications, and lower downstream costs. Many healthcare organizations see the value of an SMBP program but may not know how to start.
Today, many organizations have implemented successful SMBP programs, providing a useful roadmap and best practices, from which other healthcare providers can learn. Herein, we provide tips that can help health centres set up such essential programs for the benefit of their patients.
Components of a successful SMBP program
1. Program team
It is essential to have dedicated personnel to oversee and run the program. NACHC Million Hearts has a good staffing matrix template that can be used by practices wishing to set up. A physician assistant, pharmacist, nurse, or similarly trained health care provider is ideally suited as an SMBP project manager.
Important tasks performed by this individual include reviewing the patient panel to identify suitable patients that may benefit from an SMBP program; patient engagement and onboarding; care management and follow-up monitoring in conjunction with physicians and other members of the health care team; and graduation of successfully controlled patients. The program manager should be experienced, but also passionate, proactive, and able to work independently.
2. Software platform
This has patient-facing and provider-facing components and can include the following elements:
- Follows clinical best practice for monitoring blood pressure (including evidence-based practice and use of mean BP for clinical decision making)
- Teaches the patient how to perform BP measurements in alignment with the evidence-based guidelines.
- Available in multiple languages
- Easy for the patient to use
- Secure, aligning with best practices and regulations including HIPAA
- Interfaces with Bluetooth-enabled or cellular-equipped upper-arm positioned, clinically validated devices. Electronic transmission of BP readings eliminates errors or inaccuracies associated with manual entry.
- Customizable view of the patients enrolled in the SMBP program that supports team-based care
- Ability to onboard, graduate and re-engage patients easily and as needed
- Emphasizes usability and efficiency
- Enables sorting by risk status
- Offers EMR integration
- Provides useful analytics
- Customizable ability to message patients
- Patient engagement
3. Clinically validated upper arm blood pressure monitor
Clinically validated devices have been tested for accuracy according to standardized protocols. A list can be found at www.validatebp.org. To ensure BP measurement accuracy, is also important that the BP cuff is suitably sized for the patient’s arm.
It is often necessary to provide to the patient the ability to conduct a telehealth session with their provider. Furthermore, easy access to Social Determinants of Health resources (such as food, housing, and transportation) are more often than not essential components of an effective treatment plan for under privileged populations.
Patient selection and onboarding
All patients with elevated BP are potential candidates for an SMBP program. If resources are limited, to maximize impact, focusing initially on high-risk patients could be considered. Examples include patients with very elevated BP (e.g., 160/100 mmHg or higher) or those with pre-existing vascular disease, diabetes, or chronic kidney disease. Use of an SMBP program to follow pregnant or peripartum patients can also be considered; however, it is important to keep in mind that home BP thresholds and targets are not as well developed for this population and care should be taken to use devices that are clinically validated in pregnancy (see the stridebp.org registry for a list).
Recommendations for BP monitoring
Requiring patients to monitoring their BP daily can be onerous, tedious, and reduce patient engagement. In all global hypertension clinical practice guidelines, it is recommended that home BP monitoring be done by asking the patient to perform a home BP “series”. In the US, seven days of monitoring consisting of duplicate (2) readings in the morning and in the evening (28 readings total) is recommended. The mean is calculated and used for clinical decision making (such as medication adjustment and dose titration). Our practice is to ask our patients to do a home BP series each month if the BP is not controlled, ensure that action is taken to address the lack of control, and then reduce the frequency of monitoring to every 3 months once the BP is controlled. This reduces monitoring fatigue and increases the feasibility that long-term monitoring will be performed.
Often, the patient does not perform all required readings and so it is necessary to use what is available. A useful platform feature is therefore the ability to perform flexible averaging of readings over a defined calendar period.
Although it is preferable to implement long-term (indefinite) follow-up for patients to ensure that BP continues to be controlled, staffing and funding restraints may preclude this as an option for all patients who can benefit from an SMBP program. Accordingly, the ability to graduate a patient and onboard another is an essential part of an SMBP program. We will typically discharge a patient once the BP has been confirmed to be at target for two visits in a row, with follow-up visits being conducted in-person or virtually and spaced 4-6 weeks apart. We should also note that it is not always feasible to get to the recommended target, which is generally less than 130/80 mmHg as recommended by the US AHA/ACC 2017 guidelines. In cases where a higher target is accepted, it is important not to consider this as a failure. Indeed, reducing the BP from 180 systolic to 140-150 systolic has much greater relative impact than getting the BP down another 10 mmHg! The SMBP program should be considered a resource that needs to be allocated efficiently and, in a way, to maximize population impact.
Logistics and technology
It is important to give careful consideration to the following:
- Selecting BP devices – The www.validatebp.org website has dozens of approved peripherals. It is important to select upper arm, clinically validated devices that fit within your budget.
- Sourcing the monitoring devices – Although many options are available on the market, sourcing best-in-class devices at preferred pricing is more difficult. We are happy to provide guidance in this regard.
- Ensuring that the patient has the right mobile device to pair the monitoring devices with and that the patient is able to use the technology is essential. Patients who do not have an adequate device can be provided one that is preconfigured with the SMBP app and other helpful digital health assets and that has sufficient prepaid mobile connectivity for transmitting the measurements.
- Pairing the BP monitor with the mobile device – most clinically validated monitoring devices use Bluetooth to connect to a smartphone or tablet. It is preferable, but not essential, to ‘pre-pair’ and offer to the patient as a pre-configured kit.
- Providing tech support to the patient (and to the clinic) as needed – This avoids having care managers spend their valuable time troubleshooting technology issues. Pre-emptively selecting a platform with high usability and simplicity ratings helps minimize this potential challenge. Clinics can also supplement this by providing a tech support resource that is separate from the clinical staff.
All the above considerations can be addressed by the right vendor. For example, vendors such as mmHg and Sano Health provide the following services:
- Selection of the end-to-end solution, including a state-of-the art software platform with the features listed above.
- Sourcing and procurement of monitoring devices, and the curation of sustainably priced kits that are most appropriate for each patient cohort.
- Procurement of adequate, low-cost mobile devices and low-cost mobile data, and whenever possible, usage of government subsidies to cover the cost of the devices and the data.
- Pairing and kitting of a full solution for each patient cohort.
- Shipping the kits to the clinics, to have on hand to give to the patient, and to train the patient on using the kit. In our experience, having preconfigured kits on-site at the health center represents optimal practice because patients can then be enrolled during a face-to-face visit.
- Guidance on how to design and implement an SMBP program
- Tech support
- Assistance with administrative tasks as needed
SMBP has been proven to be a very effective modality for achieving BP control. There are now well-established programs yielding excellent outcomes and providing very helpful best practices for clinics who are looking to implement such a program to improve care for their hypertensive patients.