Title : Strengthening community-clinical linkages to improve hypertension control: Insights from the national hypertension control initiative
Abstract:
Background: Community-clinical linkages (CCLs) play a critical role in improving hypertension control among high-risk populations who face increased vulnerability due to social, economic, or environmental factors. The National Hypertension Control Initiative (NHCI), a partnership between Office of Minority Health (OMH), Health Resources and Services Administration (HRSA) and American Heart Association (AHA), integrated the American Medical Association (AMA) Measure Accurately, Act Rapidly, and Partner with Patients (MAP) framework to improve hypertension control. By bridging the gaps between Federally Qualified Health Centers (FQHCs) and community-based organizations (CBOs), NHCI enhanced patient-centered interventions.
Methods: The NHCI implemented a comprehensive, multi-faceted approach focused on four strategic areas: (1) healthcare organization and provider/clinician training, (2) community outreach and integration, (3) patient and public education, and (4) project management and evaluation. The initiative partnered with 350 HRSA-funded FQHCs with the lowest baseline blood pressure (BP) control rates (below 59%), providing tailored training and technical assistance (T/TA) guided by the AMA MAP™ framework (Measure Accurately, Act Rapidly, Partner with Patients). Standardized self-measured blood pressure (SMBP) monitoring programs were implemented to enhance measurement accuracy and patient engagement. Rapid-response strategies included enhancements to clinical workflows, provider education, and the development of culturally sensitive patient resources. To strengthen community-clinical linkages, NHCI awarded sub-grants to 12 CBOs to support outreach, health education, patient navigation, and the creation of communication and referral pathways between communities and clinical care settings. Learning collaboratives, listening sessions, and continuous engagement with stakeholders were used to identify barriers, share best practices, and support ongoing improvement of CCL efforts. Public education was advanced through digital media campaigns, public service announcements, newsletters, and an interactive NHCI website. Throughout the grant period, robust data collection and evaluation processes were used to monitor program impact, guide adjustments, and document progress in hypertension control efforts across participating FQHCs and communities.
Results: NHCI demonstrated substantial improvements in BP control among underserved populations across 350 HRSA-funded FQHCs. Between 2020 and 2023, BP control rates at participating FQHCs increased by 19.2%, with consistent gains across all racial and ethnic groups. The initiative provided evidence-based training and technical assistance to strengthen clinical capacity, with 93% of FQHCs adopting standardized BP measurement protocols and SMBP monitoring programs. CBOs played a pivotal role in reaching high-risk populations through health education, referrals, and social navigation platforms, supporting nearly 7,000 users and over 15,000 resource searches. Community members who participated in EmPOWERED to Serve health lessons demonstrated increased knowledge and confidence in managing hypertension. Community partnerships reached high-risk populations through education and outreach, supported by public campaigns generating over 1.3 billion media impressions. Key barriers, including staffing shortages, limited health literacy, and challenges in integrating SMBP technology into the Electronic Health Records system, were addressed through technical assistance and tailored capacity-building efforts.
Conclusions: Evidence-based community and clinical partnerships, such as CCLs, hold promise in addressing chronic disease like hypertension among high-risk populations. NHCI has demonstrated a scalable, patient-centered approach that strengthened hypertension control efforts through coordinated clinical care, community engagement, and strategies addressing non-medical drivers of health.
