Hypertension Self-management in Socially Disadvantaged African Americans: the Achieving Blood Pressure Control Together (ACT) Randomized Comparative Effectiveness Trial.

BACKGROUND: Effective hypertension self-management interventions are needed for socially disadvantaged African Americans, who have poorer blood pressure (BP) control compared to others. OBJECTIVE: We studied the incremental effectiveness of contextually adapted hypertension self-management interventions among socially disadvantaged African Americans. DESIGN: Randomized comparative effectiveness trial. PARTICIPANTS: One hundred fifty-nine African Americans at an urban primary care clinic. INTERVENTIONS: Participants were randomly assigned to receive (1) a community health worker ("CHW") intervention, including the provision of a home BP monitor; (2) the CHW plus additional training in shared decision-making skills ("DoMyPART"); or (3) the CHW plus additional training in self-management problem-solving ("Problem Solving"). MAIN MEASURES: We assessed group differences in BP control (systolic BP (SBP) < 140 mm Hg and diastolic BP (DBP) < 90 mmHg), over 12 months using generalized linear mixed models. We also assessed changes in SBP and DBP and participants' BP self-monitoring frequency, clinic visit patient-centeredness (i.e., extent of patient-physician discussions focused on patient emotional and psychosocial concerns), hypertension self-management behaviors, and self-efficacy. KEY RESULTS: BP control improved in all groups from baseline (36%) to 12 months (52%) with significant declines in SBP (estimated mean [95% CI] - 9.1 [- 15.1, - 3.1], - 7.4 [- 13.4, - 1.4], and - 11.3 [- 17.2, - 5.3] mmHg) and DBP (- 4.8 [- 8.3, - 1.3], - 4.0 [- 7.5, - 0.5], and - 5.4 [- 8.8, - 1.9] mmHg) for CHW, DoMyPART, and Problem Solving, respectively). There were no group differences in BP outcomes, BP self-monitor use, or clinic visit patient-centeredness. The Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 18.7 [4.0, 87.3]) and self-efficacy scores (OR [95% CI] 4.7 [1.5, 14.9]) at 12 months compared to baseline, while other groups did not. Compared to DoMyPART, the Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 5.7 [1.3, 25.5]) at 12 months. CONCLUSION: A context-adapted CHW intervention was correlated with improvements in BP control among socially disadvantaged African Americans. However, it is not clear whether improvements were the result of this intervention. Neither the addition of shared decision-making nor problem-solving self-management training to the CHW intervention further improved BP control. TRIAL REGISTRY: ClinicalTrials.gov Identifier: NCT01902719.

The Baltimore Community-Based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) Cluster RCT.

INTRODUCTION: This cluster RCT aimed to reduce healthcare utilization and increase the referral of patients between an academic health center and local community-based organizations (CBOs) that address social determinants of health. STUDY DESIGN: Cluster RCT. SETTINGS/PARTICIPANTS: Twenty-two CBOs located in Baltimore, Maryland, were randomly assigned to the intervention or control group, and 5,255 patients were allocated to the intervention or control group based on whether they lived closer to an intervention or control CBO. Data were collected in 2014-2016; the analysis was conducted in 2016. INTERVENTION: A multicomponent intervention included an online tool to help refer clients to community resources, meet-and-greet sessions between CBO staff and healthcare staff, and research assistants. MAIN OUTCOME MEASURES: The primary outcomes were patient emergency department visits and days spent in the hospital. Additional outcomes for CBO clients included knowledge of other CBOs, number of referrals to CBOs by the healthcare system, and number of referrals to healthcare system by CBOs. Outcomes for CBO staff included the number of referrals made to and received from the healthcare system and the number of referrals made to and received from other CBOs. RESULTS: There was no significant effect of the intervention on healthcare utilization outcomes, CBO client outcomes, or CBO staff outcomes. Ancillary analyses demonstrated a 2.9% increase in referrals by inpatient staff to intervention CBOs (p=0.051) and a 6.6% increase in referrals by outpatient staff to intervention CBOs between baseline and follow-up (p=0.027). Outpatient staff reported a significant reduction in barriers related to the lack of information about CBO services (-18.3%, p=0.004) and an increase in confidence in community resources (+14.4%, p=0.023) from baseline to follow-up. CONCLUSIONS: The intervention did not improve healthcare utilization outcomes but was associated with increased healthcare staff knowledge of, and confidence in, local CBOs. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT02222909.

Baltimore CONNECT: A Randomized Trial to Build Partnership Between Community Organizations and a Local Health System.

BACKGROUND: Community-based organizations (CBOs) are key partners in supporting care, but health systems and CBOs operate in silos. Baltimore Community-based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) was a randomized, controlled trial based on the core tenets of the World Health Organization's (WHO) African Partnerships for Patient Safety Community Engagement (ACE) approach. OBJECTIVES: We describe a research protocol and lessons learned from a partnership between Johns Hopkins Health System and 11 CBOs. METHODS: Baltimore CONNECT involved 22 CBOs in East Baltimore randomized to a co-developed intervention bundle versus control. Data were from review of notes and minutes from meetings, and discussions with each CBO on value added by intervention elements and on impact of the project. LESSONS LEARNED: It is feasible to engage and maintain a network of CBOs linked with a local health system. CONCLUSIONS: The WHO ACE approach supported development and sustainment of a network of organizations linking health care and social services across East Baltimore.

Implementation of a comprehensive program to improve coordination of care in an urban academic health care system.

Purpose Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue. Design/methodology/approach J-CHiP targeted adults admitted to the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, patients discharged to participating skilled nursing facilities (SNFs), and high-risk Medicare and Medicaid patients receiving primary care in eight nearby outpatient sites. The primary drivers of the program were redesigned acute care delivery, seamless transitions of care and deployment of community care teams. Findings Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health plans, hand-offs and follow-up with primary care providers, Transition Guides, a patient access line and collaboration with SNFs. Community interventions involved forming multidisciplinary care coordination teams, integrated behavioral care and new partnerships with community-based organizations. Originality/value This paper offers a detailed description of the design and implementation of a complex program to improve care coordination for high-risk patients in an urban setting. The case studies feature findings from each intervention that promoted patient engagement, strengthened collaboration with community-based organizations and improved coordination of care.

Association of a Care Coordination Model With Health Care Costs and Utilization: The Johns Hopkins Community Health Partnership (J-CHiP).

Importance: The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland. Objective: To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending. Design, Setting, and Participants: Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score-weighted and matched comparison groups. The study spanned 2012 to 2016 and took place in acute care hospitals, primary care clinics, skilled nursing facilities, and community-based organizations. The ACI analysis compared outcomes of participants in Medicare and Medicaid during their 90-day postacute episode with those of a propensity score-weighted preintervention group at Johns Hopkins Community Health Partnership hospitals and a concurrent comparison group drawn from similar Maryland hospitals. The CI analysis compared changes in outcomes of Medicare and Medicaid participants with those of a propensity score-matched comparison group of local residents. Interventions: The ACI bundle aimed to improve transition planning following discharge. The CI included enhanced care coordination and integrated behavioral support from local primary care sites in collaboration with community-based organizations. Main Outcomes and Measures: Utilization measures of hospital admissions, 30-day readmissions, and emergency department visits; quality of care measures of potentially avoidable hospitalizations, practitioner follow-up visits; and total cost of care (TCOC) for Medicare and Medicaid participants. Results: The CI group had 2154 Medicare beneficiaries (1320 [61.3%] female; mean age, 69.3 years) and 2532 Medicaid beneficiaries (1483 [67.3%] female; mean age, 55.1 years). For the CI group's Medicaid participants, aggregate TCOC reduction was $24.4 million, and reductions of hospitalizations, emergency department visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 beneficiaries, respectively. The ACI group had 26 144 beneficiary-episodes for Medicare (13 726 [52.5%] female patients; mean patient age, 68.4 years) and 13 921 beneficiary-episodes for Medicaid (7392 [53.1%] female patients; mean patient age, 52.2 years). For the ACI group's Medicare participants, there was a significant reduction in aggregate TCOC of $29.2 million with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1000 beneficiary-episodes, respectively, and reduction in practitioner follow-up visits of 41 and 29 per 1000 beneficiary-episodes for 7-day and 30-day visits, respectively. For the ACI group's Medicaid participants, there was a significant reduction in aggregate TCOC of $59.8 million and the 90-day emergency department visit rate decreased by 133 per 1000 episodes, but hospitalizations increased by 49 per 1000 episodes and practitioner follow-up visits decreased by 70 and 182 per 1000 episodes for 7-day and 30-day visits, respectively. In total, the CI and ACI were associated with $113.3 million in cost savings. Conclusions and Relevance: A care coordination model consisting of complementary bundled interventions in an urban academic environment was associated with lower spending and improved health outcomes.

How Co-Developed Are Community and Academic Partnerships?

BACKGROUND: The world-renowned resources of Johns Hopkins Hospital (JHH) in Baltimore, Maryland, stand in marked contrast with the surrounding impoverished neighborhoods. Community-based organizations (CBOs) are critical frontline responders to residents' needs. Baltimore CONNECT, an academic-community partnership, co-developed an intervention to strengthen connections between CBOs and between CBOs and the health care system. OBJECTIVES: To understand how members of an academic- community partnership define the act of "co-development" and share perceptions of barriers, facilitators, and ways to measure it. METHODS: We conducted semistructured interviews with 15 community partners, academic partners, and external stakeholders. RESULTS: Partners conceptualized co-development as a fluid and evolving process that is the outcome of shared decision making. This exploration revealed nuances within partnership dynamics, including motivations for participation, underlying incentives, partnership equality, balance of power, and trust and relation building. CONCLUSIONS: We present insights that can be used by academic researchers and community leaders looking to co-develop interventions to improve health in urban communities domestically and internationally.JHH in Baltimore, Maryland, is one of the most highly regarded hospitals in the United States. However, its institutional resources stand in marked contrast with those available to the impoverished neighborhoods that surround it. Many have called for JHH to play a greater role in the surrounding community, where it serves as a leading source of health care.

Case Study: Johns Hopkins Community Health Partnership: A model for transformation.

To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patient's primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs. The case study introduces: a) main program features including rationale, goals, intervention design, and partnership development; b) illness burden and social barriers of the population contributing to care challenges and opportunities; and c) lessons learned with steps that have been taken to engage both patients and providers more actively in the care model. Urban health systems, including academic medical centers, must continue to innovate in care delivery through programs like J-CHiP to meet the needs of their patients and communities.

Improving urban African Americans' blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial.

BACKGROUND: Given their high rates of uncontrolled blood pressure, urban African Americans comprise a particularly vulnerable subgroup of persons with hypertension. Substantial evidence has demonstrated the important role of family and community support in improving patients' management of a variety of chronic illnesses. However, studies of multi-level interventions designed specifically to improve urban African American patients' blood pressure self-management by simultaneously leveraging patient, family, and community strengths are lacking. METHODS/DESIGN: We report the protocol of the Achieving Blood Pressure Control Together (ACT) study, a randomized controlled trial designed to study the effectiveness of interventions that engage patient, family, and community-level resources to facilitate urban African American hypertensive patients' improved hypertension self-management and subsequent hypertension control. African American patients with uncontrolled hypertension receiving health care in an urban primary care clinic will be randomly assigned to receive 1) an educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem-solving intervention. All participants enrolled in the study will receive and be trained to use a digital home blood pressure machine. The primary outcome of the randomized controlled trial will be patients' blood pressure control at 12months. DISCUSSION: Results from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients' hypertension control.

Adapting hypertension self-management interventions to enhance their sustained effectiveness among urban African Americans.

African Americans suffer disproportionately poor hypertension control despite the availability of efficacious interventions. Using principles of community-based participatory research and implementation science, we adapted established hypertension self-management interventions to enhance interventions' cultural relevance and potential for sustained effectiveness among urban African Americans. We obtained input from patients and their family members, their health care providers, and community members. The process required substantial time and resources, and the adapted interventions will be tested in a randomized controlled trial.

Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members.

INTRODUCTION: We aimed to inform the design of behavioral interventions by identifying patients' and their family members' perceived facilitators and barriers to hypertension self-management. MATERIALS AND METHODS: We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients' hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants' perceptions regarding patient, family, clinic, and community-level factors influencing patients' effective hypertension self-management. RESULTS: Patient participants identified several facilitators (including family members' support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients' doctor's visits and discussions with patients' doctors outside of visits) and barriers (including their own limited health knowledge and patients' lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients' hypertension self-management. CONCLUSION: African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients' hypertension self-management. Patients' and their family members' views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.

"You've got to understand community": community perceptions on "breaking the disconnect" between researchers and communities.

BACKGROUND: Community-based participatory research (CBPR) is a growing approach to research yet its implementation does not come without challenges. Incorporating CBPR may be especially difficult for large academic medical institutions where research is conducted by different stakeholders operating under different paradigms. The Environmental Justice Partnership (EJP) is a community-academic partnership that sought to understand and address these challenges. OBJECTIVES: To know how to effectively foster collaboration between a large academic medical center and its surrounding urban community, the EJP sought to understand community stakeholders' views on research, the research process, and how to improve researcher-community collaborations. METHODS: This study used a qualitative approach to gather information from residents and representatives from community-based organizations (CBOs) and city agencies. The data are from 17 semistructured interviews and 8 focus groups (n = 80) conducted from October 2003 to May 2004. RESULTS: Respondents emphasized the importance of disseminating research findings, working closely with the community before research starts and throughout the study, and listening to community members' priorities and needs. Those with personal research experience had more positive attitudes about research than respondents who had not been in research. CONCLUSIONS: Academic institutions need to make greater effort to involve communities regularly in their community-based research to identify community priorities and concerns. Institutions may want to develop strategies for their affiliated researchers to facilitate partnership building. Especially for large academic institutions in urban settings, such efforts may help to bridge distance between researchers and community to promote the shared goal of improved public health.