A VA project uncovers barriers to success.
- Remote blood pressure monitoring combined with patient education improves blood pressure control.
- Telehealth offers a flexible and effective approach for improving the management of uncontrolled hypertension.
- Innovative strategies are required to help improve Veterans Health Administration primary care workload and panel.
According to the U.S. Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guidelines (CPG), military combat exposure can increase the risk for hypertension (HTN) in veterans. The latest data ob- tained in 2011 from VA Health Services Research & Development states that HTN is the most prevalent medical condition among veterans. (See HTN facts.)
At the Fayetteville VA Medical Center (FVAMC), managing uncontrolled HTN presents challenges due to time constraints, inadequate staffing, and overloaded patient align care teams (PACTs). Accessing most health services requires a Veterans Health Administration (VHA) primary care team, but excessive workloads result in a high turnover rate. In addition, the hiring process for all FVAMC staff takes about 4 to 6 months, which further complicates staffing issues. Current primary care panel sizes range from 700 to 1,400 veterans; some led by advance practice RNs (APRNs). The ideal panel size for an APRN is between 700 and 900 patients.
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HTN facts
According to the World Health Organization and the Centers for Disease Control and Prevention, approximately 1.28 billion individuals worldwide have been diagnosed with hypertension (HTN), which increases their risk for microvascular and macrovascular complications such as cardiovascular disease (CVD).
- HTN is associated with a strong risk for CVD compared to other risk factors such as obesity, hyperlipidemia, and tobacco use.
- According to Arnett and colleagues, a 20 mmHg higher systolic blood pressure and a 10 mmHg higher diastolic blood pressure correspond with a doubled risk for death from stroke and CVD.
- Despite interventions with proven effectiveness in HTN management, disease prevalence continues to increase.
- This preventable illness demands innovative strategies to improve health outcomes.
Barriers to care
Nursing intake (about 30 minutes for new patients and 15 minutes for follow-up visits) requires sufficient time to collect vital signs, discuss patient concerns, and complete required VHA healthcare clinical reminders. Clinicians use clinical reminders to help manage preventive care and chronic health conditions; however, the documentation process can prove arduous depending on the type of reminder. Reminders related to post-traumatic stress disorder, toxic exposure, traumatic brain injury, deployments, and military sexual trauma typically aren’t seen in civilian primary care practices. In addition, VHA policy requires that a nurse take a patient’s blood pressure (BP) three times at 5-minute intervals for any BP above 140/90 mmHg. Intake nurses also frequently reinforce patient education regarding disability claims, medications, specialty services, consults, and prosthetic items.
All of these factors can result in less time for preventive health education. In VHA primary care, most of the time available after nurse intake focuses on addressing chronic pain, mental health, and disability ratings. These conditions take at least 30 minutes to assess, which further limits diagnosing and managing common primary care conditions such as HTN, diabetes, hyperlipidemia, and obesity. In addition, administrative tasks and frequent interruptions throughout the day complicate the ability of PACTs to provide effective primary care. This overwhelming workload leads to increased burnout, call-outs, and appointment cancellations.
An innovative and multifactorial approach, such as frequent use of telehealth services by primary care clinicians, can help decrease the impact of these challenges and improve healthcare outcomes. Early diagnosis and management of HTN is instrumental in preventing long-term effects. Despite known interventions proven to treat HTN effectively, the data support a need for innovative strategies to decrease the incidence and prevalence of the condition. One PACT at FVAMC implemented a virtual approach focused on HTN management to help address barriers to care.
Evidence-based nursing
In 2017, the American Heart Association (AHA) modified their BP parameters, which lowered the threshold for diagnosing HTN. After reviewing the most updated evidence, VA/DoD adopted the new parameters in 2020. Despite this change, a gap persisted in HTN education among healthcare staff at FVAMC, which resulted in inconsistent information provided to veterans.
When performed correctly, patient education can help improve patient health literacy and save costs for the patient and the health system. A systematic review of 18 randomized control trials by Tan and colleagues found that virtual education sessions conducted at home rather than education sessions conducted in a clinic resulted in better medication adherence for patients with HTN, diabetes, and hyperlipidemia. Hoppe and colleagues and Tan and colleagues noted that digital tools such as virtual educational programs, mobile applications, and remote monitoring improved BP control, quality of life, cost effectiveness, and patient adherence. Despite these positive effects, insufficient evidence exists for telehealth use with veterans overall and veterans with uncontrolled HTN specifically.
Various studies examining the effects of telemonitoring in primary care settings show favorable results in patient outcomes. Remote BP monitoring, for example, allows patients to take their BP in a familiar and comfortable environment, which reduces the white coat HTN frequently seen in clinic settings. Virtual modalities also provide flexibility and can be used by any healthcare professional. Hoppe and colleagues showed the association between the use of remote monitoring in combination with standardized HTN management and reduced hospital readmissions and improved BP control. In a pilot video of BP innovation at the VA Boston Health Care System and the Gulf Coast Veterans Health Care System, 96% of patients recommended virtual BP visits and 87% preferred virtual BP visits over traditional in-person visits. In addition, 100% of clinicians reported satisfaction with virtual video BP visits to manage HTN. Remote monitoring allows timelier treatment decisions, which can optimize HTN management.
Virtual HTN clinic
We conducted this quality improvement (QI) project to address the management of uncontrolled HTN in veterans within primary care. The goal was to pilot a virtual hypertension clinic and evaluate its effects on disease management in veterans. We had three aims: decrease systolic BP and/or diastolic BP by 5 mmHg for 20% of enrolled participants with uncontrolled HTN by the end of the pilot, increase use of virtual video connect visits by 5% among the PACT, and achieve at least 50% remote monitoring adherence by the end of the pilot.
What we did
Members of the PACT reviewed the schedule daily to identify potential participants who met inclusion criteria (last documented systolic BP above 130 mmHg and/or diastolic BP above 80 mmHg). Exclusion criteria included secondary causes of HTN, cancer, cirrhosis, estimated glomerular filtration rate <30 mL/min, dialysis, and prescriptions for more than three antihypertensives. A sample size of 27 veterans consented verbally to the pilot. Patient responsibilities included taking their BP daily via a VA-issued validated sphygmomanometer, at least one telephone encounter with the PACT RN, and at least one virtual visit with the PACT provider. The single-arm prospective cohort study design compared baseline BPs (last documented BP greater than 130/80 mmHg in the electronic health record [EHR]) to those after the intervention.
The pilot ran for 12 weeks. Participants received a packet of HTN educational resources, which included an updated BP chart from the AHA as well as VHA patient education printouts.
The PACT team entered home telehealth consults for the participants, which required additional processing by the receiving telehealth nurse. The nurse provided additional education and mailed a kit to participants for uploading their BP. Before the virtual clinic, enrolled participants received virtual video connect education from the PACT licensed practical nurse (LPN) or RN. During the RN telephone visit, the RN reviewed the educational packets and current BPs with the participants. Veterans received education on how to take BP measurements, such as keeping the arm above heart level and not crossing the legs. The RN ordered a complete blood count, lipid panel, and comprehensive metabolic panel if one wasn’t in the EHR within 6 months. Some veterans participated in several virtual encounters with PACT depending on factors such as medication changes, abnormal labs, and abnormal BPs.
One month after the RN visit, the PACT scheduled participants for a 60-minute virtual visit with their primary care provider. During this visit, the LPN completed patient care clinical reminders and entered updated BP and heart rate data into the EHR. The provider also offered additional HTN education, reviewed labs, and updated the plan of care as needed. (See Statistical analysis and results.)
Statistical analysis and results
The project team performed its statistical analysis using IBM SPSS version 28 with a level of significance set to P < .05. The patient aligned care team (PACT) licensed practical nurse entered data, and the primary investigator validated all values to ensure accuracy.
- To examine Aim 1, difference scores from pre- to postintervention for systolic blood pressure (BP) and diastolic BP were computed and coded into a dichotomous variable using 1 = decrease of 5 or more and 0 = decrease of less than 5. The percentages with a decrease of 5 or more for systolic BP, diastolic BP, and both were computed and compared against the 20% goal rate. In addition, paired t-tests were conducted to determine whether BP readings showed a statistically significant change after intervention.
- For analysis of Aim 2, the virtual video connect rate pre- and postintervention from VHA Support Service Center Capital Assets (VSSC) were used. Data were extracted from VSSC databases.
- For Aim 3, BP monitoring adherence rates were compared using a percentage difference calculation to determine whether the 50%
increase was met.
Results
Of the 27 veterans who initially enrolled in the virtual clinic, 18 completed the project. Of the initial sample, all were men, 18 were Black, eight were White, and one was Native American. Remote BP monitoring adherence was the main reason many didn’t complete the project. Contributing factors for nonadherence included knowledge, age, and culture. Some simply no longer wanted to participate. Of the 18 veterans who completed the project, 61.1% were Black and 38.9% were White. Mean age was 54.89 (SD = 10.93) years with a range from 39
to 72.
According to Oparil and colleagues, a BP reduction by a few millimeters of mercury can meaningfully decrease mortality risk. A systolic BP reduction of 5 mmHg can decrease stroke mortality by 14% and CVD mortality by 9%.
In this pilot, the systolic BP baseline mean of 148.61 mmHg (SD = 11.21) decreased to 128.83 (SD = 11.55), t (17) = 7.07, P <.001. The diastolic BP baseline mean of 86.28 mmHg (SD = 11.45) decreased to 78.0 (SD = 11.71), t (17) = 2.30, P = .034. The average decline for systolic BP was 19.78 mmHg, and the average decline for diastolic BP was 8.28 mmHg. Analysis also showed that 94.4% (17 out of 18) of participants had a decline of 5 mmHg or more for their systolic BP, and 66.7% (12 out of 18) had a decline of 5 mmHg or more for their diastolic BP.
PACT use of the virtual video clinic increased from 0% to 27.7% from June 2022 to August 2022. Use also increased among veterans, which improved their comfort level for future use. Thirteen veterans took their BP as instructed (72.2%), and five did not (27.8%). Despite the statistical insignificance of the data, two veterans participated in and completed the project using a VA-issued tablet, which improved their BP control.
What we learned
During the course of the pilot, we discovered barriers to successful implementation of a virtual HTN clinic, including staff shortages, knowledge gaps among clinic staff, and inconsistent scheduling grids.
Staff shortages. The staffing turnover rate continues to increase among nurses and clinical providers at FVAMC. Cancellation of traditional in-person appointments prevents the collection of data critical to effective HTN treatment, which interferes with timely interventions and follow up. Despite cancelled appointments due to call-outs from burnout or staff turnover, the virtual clinic allowed veterans to continue remote BP monitoring.
Staffing shortages resulted in some veterans enrolling in telehealth after we initiated the virtual clinic. For example, from March to July 2022, the pilot PACT lost two key team members, the LPN and RN. Both had transitioned into other VHA positions due to the strenuous primary care workload.
Before the pilot, we found that the home telehealth (HTH) department also experienced a staffing shortage and that program eligibility requirements were based on the VHA national guidelines of a BP of <140/90 mmHG, rather than the VA/DoD CPG of <130/80 mmHg. Some veterans enrolled in the project with a BP of <140/90 mmHg experienced delays in telehealth consult processing due to the eligibility guidelines. These unfortunate events resulted in some veterans receiving delayed HTH consults.
Knowledge gap. During virtual clinic follow-up visits with the primary care providers, some veterans received outdated BP information from the nursing staff in HTH and primary care. Several clinic staff weren’t aware of the updated AHA BP categories, which likely resulted from inconsistent BP standards within the VA enterprise. Although the VA/DoD guideline committee supports the 2017 AHA BP guidelines, the VHA national guidelines are 10 mmHg higher.
During chart review, we found inconsistent information among nursing staff throughout the enterprise regarding when to take blood pressures. This caused some confusion among veterans, which required additional education and reinforcement during their primary care provider appointment. Consistent patient education among clinic staff in conjunction with telehealth may help improve HTN management among veterans.
Scheduling grid. Telehealth continues to transform how individuals receive healthcare across the world, and increased use of primary care settings can benefit patients with chronic illness who require frequent followup. Sustainability of a virtual HTN clinic in primary care is questionable, as it requires support of and collaboration with administrative and clinic staff. Primary care administrative staff typically coordinate and assist with special requests to allow modifications of providers’ scheduling grids; however, the pilot shows the need for more support. Currently, no support exists for developing appropriate scheduling grids for regular patient encounters, which leads providers to shy away from using virtual VHA applications such as virtual video connect.
Address barriers to telehealth success
Telehealth can significantly improve access to care. Its use for managing chronic diseases such as HTN improves patient outcomes and can help decrease hospitalizations. It can serve as a cost-effective and flexible innovation for improving health outcomes in veterans with uncontrolled HTN who also may experience chronic pain that prevents them from attending in-person appointments. To ensure consistent and effective application of telehealth, we must address implementation barriers. Work with nursing and organization leadership to develop solutions to the challenges of staff shortages, knowledge gaps among healthcare professionals, and administrative roadblocks.
Ron’Nisha D. Baldwin is a board-certified adult gerontological primary care nurse practitioner in the Department of Veteran Affairs and a consulting associate in the Duke University School of Nursing. Bradi Granger is a research professor at Duke University Health System and Duke University School of Nursing. Julie Thompson is a consulting associate in the Duke University School of Nursing. Margaret T. Bowers is a cardiology nurse practitioner in the Duke University Health System and a clinical professor in the Duke University School of Nursing. Audrey Kizzie is a health promotion, disease prevention program manager in the Department of Veteran Affairs.
American Nurse Journal. 2023; 18(11). Doi: 10.51256/ANJ11232326
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Key words: hypertension, remote blood pressure monitoring, patient education, veterans’ health
