Reducing Inequities in Care of Hypertension, Lifestyle Improvement for Everyone (RICH LIFE Project)
Condition: Uncontrolled Hypertension
MeSH terms: Hypertension
Study type: Interventional

Summary: 
      The RICH LIFE Project is a two-armed, cluster-randomized trial, comparing the effectiveness
      of an enhanced standard of care arm, "Standard of Care Plus" (SCP), to a multi-level
      intervention, "Collaborative Care/Stepped Care" (CC/SC), in improving blood pressure control,
      patient activation and reducing disparities in blood pressure control among 1,890 adult
      patients with uncontrolled hypertension and cardiovascular disease risk factors at thirty
      primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP
      arm receive standardized blood pressure measurement training, and audit and feedback of blood
      pressure control rates at the practice provider level. Fifteen practices in the CC/SC arm
      receive all the SCP interventions plus the implementation of the collaborative care model
      with additional stepped-care components of community health worker referrals and
      subspecialist curbside consults and an on-going virtual workshop for organizational leaders
      in quality improvement and disparities reduction. The primary clinical outcomes are the
      percent of patients with blood pressure <140/90 mm Hg and change from baseline in mean
      systolic blood pressure at 12 months. The primary patient reported outcome is change from
      baseline in self-reported patient activation at 12 months.
    

Detailed description: 
      The investigators refined research aim is to determine if a clinic-based collaborative care
      team, including a community health worker (CHW) to deliver community-based contextualized
      care, reduces disparities in blood pressure control rates, lowers cardiovascular disease
      (CVD) risk, and improves outcomes among patients with hypertension and other common comorbid
      conditions when compared to standard of care health system approaches to CVD risk management,
      including audit and feedback and staff and provider training.

      Collaborative care includes care coordination and care management; regular and proactive
      monitoring and treatment to target specific patient needs using validated clinical tools and
      rating scales; and regular systematic caseload reviews by the care team and consultation with
      experts for patients who do not show clinical improvement. A typical collaborative care team
      includes the primary care provider, nurse care manager or coordinator, and other members of
      the clinic staff involved in patient care.

      Intervention protocols are designed to address common comorbidities (diabetes,
      hyperlipidemia, depression and coronary heart disease), lifestyle factors (dietary intake,
      physical activity, and smoking) and medication adherence. The intensive intervention treats
      the "whole" patient, driven by individual patient goals and priorities, as opposed to the
      standard of care, which typically focuses on individual conditions. This proposed study
      responds directly to patient desires to feel more equipped to be involved in their care and
      manage multiple conditions that contribute to CVD. The investigators have worked successfully
      in the past with a broad range of stakeholders, including community members, patients,
      providers, and payors, and will continue to engage them through the research and
      dissemination process.
    

Intervention name(s): Provider Audit-Feedback, Stratified by Race and Ethnicity; Blood Pressure Measurement Standardization; System Level Leadership Intervention; Collaborative Care Team Intervention; Community Health Worker Referral; Specialist Care Consultation
Intervention type(s): Behavioral; Behavioral; Behavioral; Behavioral; Behavioral; Behavioral
Intervention description(s): Transparent and timely access to and review of clinical performance data are among the key elements of successful improvement activities. The RICH LIFE Project provides the health systems with the logic to build practice and provider level hypertension (HTN) dashboards, support in building the dashboard, and education in utilizing the dashboard. The practice dashboard provides a display of the percentage of patients achieving BP control, defined as <140/90 mm Hg for the overall practice, while the provider dashboard provides a display of the percentage of patients achieving BP control for each provider's patient panel. Both the practice and provider Dashboards stratify hypertension performance data by race (White, non-Hispanic; Black, non-Hispanic; and All Hispanic) to help practice administration and clinicians evaluate differences between races and ethnicities in BP control rates. New reports are generated at least quarterly and will display data from the previous 3 months.; All adult medicine staff at participating study practices receive standardized, evidence-based, best practices BP measurement training. Aspects of the training include proper patient preparation and positioning, how use of an automated BP measurement device, and executing a "screen and confirm" protocol when measuring patients' blood pressures.; This System-Level Leadership intervention aims to create a learning network through an inter-organizational approach to promote health equity and reduce CVD disparities. Elements of the system-level leadership intervention, then, include: 1) an introductory session during the kick-off event (baseline); 2) a quarterly 1 hour "content call" with a presentation on leading for equity and discussion among system-level leaders, community organization leaders, and interested practice champions in the CC/Stepped care arm conducted via conference call/webinar; and 3) monthly "coaching calls" for the system and practice level leaders, CMs, and CHWs in the CC/stepped care arm to discuss the interventions, while they are actively engaged in the intervention phase.; The collaborative care intervention creates a collaborative care team that, at a minimum, consists of PCP, nurse, or social worker care manager, and community health worker. The collaborative care team develops the medical management plan in partnership with patients; 2) uses care coordination to maximize interaction of the patients' PCPs with other care providers addressing medication management, patient self-management, and psychosocial support on a regular, consistent basis; and 3) determines patient access to CHW support and subspecialty consultations.; As a "stepped up" component of the Collaborative Care Team Intervention for patients needing support in overcoming a variety of social determinants; As a "stepped up" component of the Collaborative Care Team Intervention for patients with complex medical conditions and/or patients that may not typically have access to specialist care
Other intervention name(s): Stratified Hypertension Dashboard; Collaborative Care Model
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment