SHEBOYGAN COUNTY, WI – Interrupted access to primary care during COVID-19 has impacted the level of hypertension in more than 100 million American adults. Often, the burden of high blood pressure falls disproportionately on some segments of the population – with low-income Wisconsinites nearly 33% more likely to have high blood pressure than their middle-class neighbors.

In Sheboygan and Manitowoc Counties, Lakeshore Community Health Care (LCHC) serves as the primary safety net clinic for area residents. LCHC is committed to providing best possible care – and outcomes – for their patients which is why they were excited to participate in HRSA’s National Hypertension Control Initiative. The initiative centers on the launch of a Self-Measured Blood Pressure program while providing resources to improve blood pressure control overall.   

The American Heart Association has been pleased to support this work as it evolves. The first step was to establish a Self-Measured Blood Pressure (SMBP) program to empower patients to check their blood pressure at home, with the results uploaded into their Electronic Health Record (EHR) at LCHC. Following some initial pilots and trials throughout late 2021 and early 2022, LCHC’s comprehensive SMBP program was firmly established by July 2022, after the spring launch of their new EHR software OCHIN Epic.

“Prevention has been the team’s focus. We have used a variety of means to assist in educating patients on the signs of High Blood Pressure, the value of taking their medications consistently and the long-term impact of BP control to their overall health. Prevention highlights our population health strategy,” explained Brenda Georgenson, LCHC’s Director of Quality Improvement.

Throughout the process, the organization focused on emphasizing quality and best practices. Using data from their population health software, Azara (adopted in 2020), LCHC stratified patient risk and coordinated a large recruitment effort for patients using letters, phone calls, and provider-led conversations. They also identified the validated blood pressure monitors that would work best for their needs and worked on an integrated approach, engaging their pharmacy staff in the process of recruiting and onboarding patients.

While embracing the opportunity to engage a cohort of patients in SMBP, the team at LCHC also knew that many patients would not participate in the program for a variety of reasons; lack of understanding technology was anticipated to be the greatest reason. To help mitigate those concerns, the LCHC team ensured that simplicity of use was a factor when deciding on a monitor and that patients were comfortable with how to take their blood pressure while streamlining the data sharing as much as possible.

Importantly, the organization knows there is more work to be done. Through connections facilitated by the American Heart Association, the Federally Qualified Health Center is relocating an unused hydroponic growing tower to a local food service organization – with the possibility of some of that produce coming back to their patients. They are also seeking to work with the Manitowoc County Health Department to be a referral site for BP screenings, especially in the rural areas of the County. 

Sr. Rural Health Director for the American Heart Association, Tim Nikolai, said, “It was fantastic to work with the LCHC team on this project. The timing of the EHR upgrade added to some challenges getting everything up and running, but it also allowed for opportunities to refine the process and meet the requirements of the grant. I’m excited to see the impact this work will have.”


About the American Heart Association
The American Heart Association is a relentless force for a world of longer, healthier lives. We are dedicated to ensuring equitable health in all communities. Through collaboration with numerous organizations, and powered by millions of volunteers, we fund innovative research, advocate for the public’s health and share lifesaving resources. The Dallas-based organization has been a leading source of health information for nearly a century. Connect with us on heart.orgFacebookTwitter or by calling 1-800-AHA-USA1.   

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