Abstract
Purpose: Worldwide, 1.28 billion adults between 30-79 years of age have Hypertension (HTN) (WHO, 2023). HTN is the most common medical diagnosis in the U.S. and individuals with social, economic, and cultural factors have higher prevalence and poor control of their ability to self-manage the disease (Ware, Chidume, & Chou, 2023). HTN has the highest risk for mortality related to cardiovascular disease (Cheng et al., 2022). Care coordination and CHWs provide resources, especially those related to social determinants of health (SDOH), and can improve patient engagement and support improved quality of care (Ibe et al., 2021). SDOH increases the prevalence of mortality resulting from cardiovascular disease (CDC, 2023).
Methodology: Using the Plan, Do, Study, Act methodology, the following quality improvement project was implemented: 1. Two Chronic Disease nurses filtered a facility-specific Chronic Disease Dashboard to identify patients ages 40-75 with a clinical diagnosis of HTN and uncontrolled clinic B/P ≥140/90 after two PCP visits. 2. Motivational interviewing was used to identify patients who did not express or exhibit readiness for self-care management, which was used as exclusion criteria. 3. For the patients who met the inclusion criteria (n=51), the nurses implemented targeted nursing interventions over a 3-month period (April to June) which included: a) Comprehensive education tailored to the individual patient’s needs; b) Home B/P monitoring with log book; c) Collaborative care planning; d) Monthly telehealth outreach and in-person nurse visits; and e) SDOH screening and referrals to CHWs for internal/external resources as indicated.
Analysis: Within a 3-month period, 76% of patients with uncontrolled HTN reduced their clinic B/P from ≥140/90 to <130/80 (n=34). Monthly telehealth outreach/education and SDOH screening were completed in 100% of the patients (n=51). SDOH were identified or self-reported and addressed via the provision of grant-funded home B/P machines patients with financial needs (n=12; 24%) and referrals to CHWs for resources as indicated: housing, food, transportation, smartphone access for care team communication, educational, employment, and legal assistance (n=7; 14%).
Results: This quality improvement project showed that 76% of patients with clinic B/P ≥140/90 improved their clinic B/P to ≤130/80 over a 3-month period. Using telehealth outreach services and addressing SDOH supported engagement and quality patient outcomes.
Notes
References:
Centers for Disease Control and Prevention [CDC]. (2023). Excess burden of poverty and hypertension, by race and ethnicity, on the prevalence of cardiovascular disease. https://www.cdc.gov/pcd/issues/2023/23_0065.htm#:~:text=Some%20racial%20and%20ethnic%20minority,development%20and%20course%20of%20CVD.
Ibe, C.A., Alvarez, C., Carson, K.A., Marsteller, J.A., Crews, D.C., Dietz, K.B., Greer, R.C., Bone, L., & Cooper, L.A. (2021). Social determinants of health as potential influencers of a collaborative care intervention for patients with hypertension. Ethnicity & Disease, 31(1), 47-56. https://doi.org/10.18865/ED.31.1.47
Ware, K.S., Chidume, T., & Chou, C. (2023). Social determinants of health and preventable emergency department patient encounters among adults with hypertension. Public Health Nursing, 40(1), 171-174. https://doi.org/10.1111/phn.13152
Cheng, W., Du, Y., Zhang, Q., Wang, X., He, C., He, J., Jing, F., Ren, H., Guo, M., Tian, J., & Xu, Z. (2022). Age-related changes in the risk of high blood pressure. Frontiers in Cardiovascular Medicine, 9. https://doi.org/10.3389/fcvm.2022.939103
World Health Organization [WHO] (2023). Hypertension. https://www.who.int/news-room/fact-sheets/detail/hypertension
Sigma Membership
Phi Pi
Type
Poster
Format Type
Text-based Document
Study Design/Type
Quality Improvement
Research Approach
Translational Research/Evidence-based Practice
Keywords:
Health Equity, Social Determinants of Health, Public and Community Health, Mentoring and Coaching
Recommended Citation
Uguru, Jenny, "Hypertension Management and Addressing Health Equity" (2026). International Nursing Research Congress (INRC). 3.
https://www.sigmarepository.org/inrc/2026/posters_2026/3
Conference Name
37th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Toronto, Ontario, Canada
Conference Year
2026
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2026-07-20
Hypertension Management and Addressing Health Equity
Toronto, Ontario, Canada
Purpose: Worldwide, 1.28 billion adults between 30-79 years of age have Hypertension (HTN) (WHO, 2023). HTN is the most common medical diagnosis in the U.S. and individuals with social, economic, and cultural factors have higher prevalence and poor control of their ability to self-manage the disease (Ware, Chidume, & Chou, 2023). HTN has the highest risk for mortality related to cardiovascular disease (Cheng et al., 2022). Care coordination and CHWs provide resources, especially those related to social determinants of health (SDOH), and can improve patient engagement and support improved quality of care (Ibe et al., 2021). SDOH increases the prevalence of mortality resulting from cardiovascular disease (CDC, 2023).
Methodology: Using the Plan, Do, Study, Act methodology, the following quality improvement project was implemented: 1. Two Chronic Disease nurses filtered a facility-specific Chronic Disease Dashboard to identify patients ages 40-75 with a clinical diagnosis of HTN and uncontrolled clinic B/P ≥140/90 after two PCP visits. 2. Motivational interviewing was used to identify patients who did not express or exhibit readiness for self-care management, which was used as exclusion criteria. 3. For the patients who met the inclusion criteria (n=51), the nurses implemented targeted nursing interventions over a 3-month period (April to June) which included: a) Comprehensive education tailored to the individual patient’s needs; b) Home B/P monitoring with log book; c) Collaborative care planning; d) Monthly telehealth outreach and in-person nurse visits; and e) SDOH screening and referrals to CHWs for internal/external resources as indicated.
Analysis: Within a 3-month period, 76% of patients with uncontrolled HTN reduced their clinic B/P from ≥140/90 to <130/80 (n=34). Monthly telehealth outreach/education and SDOH screening were completed in 100% of the patients (n=51). SDOH were identified or self-reported and addressed via the provision of grant-funded home B/P machines patients with financial needs (n=12; 24%) and referrals to CHWs for resources as indicated: housing, food, transportation, smartphone access for care team communication, educational, employment, and legal assistance (n=7; 14%).
Results: This quality improvement project showed that 76% of patients with clinic B/P ≥140/90 improved their clinic B/P to ≤130/80 over a 3-month period. Using telehealth outreach services and addressing SDOH supported engagement and quality patient outcomes.
Description
Focus: Clinical
Status: Complete Work/Project
Effective hypertension management was achieved in 76% of patients with hypertension through engagement in self-care management and using telehealth to engage and outreach patients. Addressing SDOH such as financial concerns, food and housing insecurities supports the removal of barriers which negatively impact disease management and overall health and well-being. Implementing targeted and evidence-based nursing interventions addresses both the chronic disease and socio-economic needs.