Abstract
The design, implementation, and impact of a pharmacist-led employee wellness hypertension program that utilizes remote blood pressure monitoring are described.
Employees of a private university and health insurance beneficiaries with a diagnosis of hypertension or a documented high blood pressure reading at a previous screening encounter were eligible to participate in the program. Participants received a remote blood pressure monitoring device and followed up with a pharmacist in person or via telehealth throughout the program. The pharmacist provided education on lifestyle modifications to improve blood pressure control, and recommendations regarding changes to the participant’s medication therapy were made to the participant’s primary care provider. Participants completed an in-person appointment at month 3 of the program for blood pressure reassessment. Twenty-four participants were enrolled in the program. The mean baseline systolic and diastolic blood pressures were 134 mm Hg and 85 mm Hg, respectively. Of the total of 24 participants, 18 participants (75%) had a blood pressure above their goal at baseline. At month 3 of the program, 7 of these 18 participants (39%) had achieved their blood pressure goal, with average systolic and diastolic blood pressure decreases of 8.9 mm Hg and 7.8 mm Hg, respectively. Pharmacist recommendations to primary care providers regarding medication changes had an acceptance rate of 70%.
A pharmacist-led employee wellness hypertension monitoring program that utilized remote monitoring devices improved employee blood pressure control through education on lifestyle modifications and medication recommendations to the participants’ primary care providers.
Cardiovascular disease continues to be the leading cause of death in the United States, with over 900,000 deaths being attributed to cardiovascular disease in 2020.1 Cardiovascular disease is the most expensive disease in the United States, with direct and indirect costs of around $400 billion from 2018 to 2019.1,2 Nearly 50% of adults in the United States have a diagnosis of hypertension; however, only 25% of adults with hypertension have their blood pressure controlled according to American Heart Association (AHA)/American College of Cardiology (ACC) 2017 guideline.3 Hypertension is the top modifiable risk factor for the development of cardiovascular disease and ranks within the top 10 most expensive conditions for employers.4–7
Because of the cost burden of hypertension, employers have developed various wellness programs to assist employees with blood pressure management, and pharmacists have been involved in these programs to help patients achieve blood pressure control and improve outcomes.8 This is partly due to pharmacists’ role in addressing clinical inertia around hypertension management, which can be a barrier to patients reaching their goals.9 Clinical inertia, which occurs when treatment is not initiated or intensified when appropriate, is due to various factors, including time constraints during a patient’s appointment with their provider, lack of knowledge about appropriate goals, and not being aggressive enough with treatment.10,11 Pharmacist recommendations regarding hypertension treatment can address clinical inertia and help patients achieve blood pressure goals. Telemedicine has had an increasing role in the management of chronic diseases, including hypertension, especially since the COVID-19 pandemic.12 Remote patient monitoring can be utilized to send blood pressure data directly to a healthcare profession for telehealth management of patients, resulting in improved blood pressure control for patients without coming into the office.
The purposes of this article are (1) to describe the design and implementation of a pharmacist-led employee wellness remote blood pressure monitoring program implemented within an employee wellness clinic and a community pharmacy and (2) to describe the program’s impact on employee blood pressure control over a 3-month period.
Program implementation
Ohio Northern University (ONU) is a small, private, self-insured university with around 700 employees and 1,000 medical beneficiaries. ONU has a college of pharmacy, The Raabe College of Pharmacy, and provides pharmacy services to employees and the community through ONU HealthWise, which includes an on-campus independent pharmacy and a pharmacist-led employee wellness clinic. The employee wellness clinic and the pharmacy are located in the same physical space, and there is overlap in the pharmacists who complete patient appointments in the clinic and those who staff the pharmacy. Pharmacists were not required to have special credentialing to manage patients in the remote blood pressure monitoring program, and pharmacists involved in providing services throughout the program included community pharmacists, postgraduate year 1 pharmacy residents, and board-certified ambulatory care pharmacists who were faculty at ONU.
Pharmacist involvement in hypertension management and the use of remote hypertension monitoring devices can help combat clinical inertia to optimize patients’ hypertension control.
A pharmacist-led remote hypertension monitoring program, implemented within an employee wellness clinic and community pharmacy, has had a positive impact on hypertension outcomes of program participants.
The program described can serve as a model for other pharmacies to develop and implement a similar remote blood pressure monitoring program.
Enrollment and in-person follow-up appointments for the employee blood pressure monitoring program are held in the clinic rooms next to the pharmacy, and the other tasks, including contacting providers and telehealth participant follow-up appointments, are completed through the pharmacy. At the time of program initiation, the pharmacy was staffed by pharmacists, pharmacy student interns, and introductory pharmacy practice experience (IPPE) students. Pharmacy interns and IPPE students had similar roles in assisting the pharmacists with various tasks related to the program. Under the supervision of a pharmacist preceptor, interns and IPPE students contacted primary care providers’ offices when a patient expressed interest in enrolling in the program, reviewed participants’ blood pressure readings each week and completed documentation of these readings, contacted participants for follow up on their readings, and contacted primary care providers’ offices to recommend changes to medication therapy. Weekly review of blood pressure readings and pharmacy interventions were documented in a participant’s profile within the pharmacy’s medication dispensing software, PioneerRx (PioneerRx, Irving, TX), for internal use by the pharmacy staff only. All communication with primary care providers’ offices was conducted via telephone call and fax.
Participants eligible to enroll in the institutional review board–approved employee wellness hypertension monitoring program included employees and health insurance beneficiaries 18 years of age or older who had a diagnosis of hypertension, were taking antihypertensive medication, or had a high blood pressure reading at a previous screening encounter documented in their pharmacy profile. All employees were notified about the program and eligibility requirements through an email sent to all employees. Any interested employees called or emailed the pharmacy to schedule an initial appointment to enroll. At the 30-minute initial appointment, which was completed with a pharmacist, baseline blood pressure was obtained, blood pressure goals were established per the 2017 ACC/AHA guideline, and education was provided on use of the blood pressure device and the correct technique to measure blood pressure at home. The preferred communication method of participants in the program was obtained. If participants preferred to not receive text messages or email communication, a note was made in their medication profile at the pharmacy to call the participant for any communications. After the initial appointment, a follow-up email was sent to participants with an infographic on proper blood pressure technique and directions to set up an account to view their blood pressure readings with the online platform.
After the enrollment appointment, the pharmacy called a participant’s primary care provider to inform them about the program and faxed an acknowledgment form for the provider to sign. The offices for the majority of participants’ primary care providers were located within a 30-mile radius of the pharmacy and were not directly associated with ONU. Once the signed acknowledgment form was received from the primary care provider, the participant was provided with a remote blood pressure monitoring device. The devices utilized were iBloodPressure Classic wireless blood pressure cuffs (Smart Meter, LLC, Tampa, FL), which transmitted patient readings over the cellular network to an online platform accessible to both the program participants and the pharmacy. The cost of the blood pressure devices was supported by funds from a research grant from the ASHP Research and Education Foundation.
The pharmacy ordered the blood pressure device to be shipped directly to a participant’s home, and a text message was sent from the pharmacy’s dispensing software to participants when the pharmacy ordered the device. A follow-up text message was sent to participants 5 days after the device was ordered to confirm the device was received.
Participants were instructed to utilize the device 3 times per week, at minimum; however, the pharmacist could request that a participant utilize the device more frequently, if appropriate. A pharmacist and student pharmacists reviewed the participants’ readings once weekly to assess blood pressure control and followed up with participants as-needed throughout the program. Participants with controlled blood pressure (<130/80 mm Hg) were contacted monthly via secure email to inform them their readings were at goal and to encourage continued use of the device. Participants with uncontrolled blood pressure were contacted monthly, at minimum, for a 15- to 30-minute follow-up appointment, conducted either in person or via telehealth call, to discuss their blood pressure readings. At the follow-up appointments, the pharmacist utilized the Pharmacist’s Patient Care Process to collect relevant information from participants regarding their home blood pressure monitoring technique and adherence to medication, assess participant home blood pressure readings from the online platform, and develop a plan with the participant including discussion of lifestyle modifications to improve blood pressure control and potential changes to medication therapy. In developing recommendations for changes to antihypertensive medication therapy, the pharmacist considered patient-specific factors, including medication adherence and comorbidities, and followed the recommendations outlined in the 2017 ACC/AHA guideline. To implement changes to medication therapy, the pharmacy called the primary care provider’s office to make a verbal recommendation and sent a fax with the participant’s most recent blood pressure readings. A report of the participant’s blood pressure readings was downloaded and faxed to the participant’s primary care provider when the participant had a scheduled appointment with their provider. If participants did not utilize the device at least 3 times within the past week, an adherence text message was sent to remind the participants to check their blood pressure.
Participants completed an in-person follow-up appointment with a pharmacist at month 3 of the program for blood pressure reassessment. To incentivize participation in the program, participants who utilized the device at least 3 times per week and completed the 3-month follow-up were awarded wellness points to spend at businesses located on campus.
The pharmacy invoiced the employer directly for patient care services utilizing established Current Procedural Terminology codes.
Outcomes and impact
Twenty-four participants enrolled in the program, with 100% of the interested participants’ primary care providers successfully acknowledging their participation. Baseline characteristics of program participants are summarized in Table 1. The mean age was 53 years, 50% of the participants were male, and 88% of the participants were white. The mean baseline systolic and diastolic blood pressures were 134 mm Hg and 85 mm Hg, respectively. At baseline, 33% of participants did not have a diagnosis of hypertension and 71% of participants had a blood pressure above the goal of 130/80 mm Hg.
Baseline Characteristics of Participants in Remote BP Monitoring Program (N = 24)
| Variable | Value |
|---|---|
| Age, mean, years | 53 |
| Male, No. (%) | 12 (50) |
| Race, No. (%) | |
| White | 21 (88) |
| Asian | 3 (12) |
| Black/African American | 0 |
| Other | 0 |
| Systolic BP, mean, mm Hg | 134 |
| Diastolic BP, mean, mm Hg | 85 |
| Diagnosis of hypertension, No. (%) | 16 (67) |
| BP >130/80 mm Hg | 18 (75) |
| No. of antihypertensive medications used, No. (%) | |
| 0 | 8 (33) |
| 1 | 13 (54) |
| 2 | 2 (8) |
| ≥3 | 1 (4) |
| Variable | Value |
|---|---|
| Age, mean, years | 53 |
| Male, No. (%) | 12 (50) |
| Race, No. (%) | |
| White | 21 (88) |
| Asian | 3 (12) |
| Black/African American | 0 |
| Other | 0 |
| Systolic BP, mean, mm Hg | 134 |
| Diastolic BP, mean, mm Hg | 85 |
| Diagnosis of hypertension, No. (%) | 16 (67) |
| BP >130/80 mm Hg | 18 (75) |
| No. of antihypertensive medications used, No. (%) | |
| 0 | 8 (33) |
| 1 | 13 (54) |
| 2 | 2 (8) |
| ≥3 | 1 (4) |
Baseline Characteristics of Participants in Remote BP Monitoring Program (N = 24)
| Variable | Value |
|---|---|
| Age, mean, years | 53 |
| Male, No. (%) | 12 (50) |
| Race, No. (%) | |
| White | 21 (88) |
| Asian | 3 (12) |
| Black/African American | 0 |
| Other | 0 |
| Systolic BP, mean, mm Hg | 134 |
| Diastolic BP, mean, mm Hg | 85 |
| Diagnosis of hypertension, No. (%) | 16 (67) |
| BP >130/80 mm Hg | 18 (75) |
| No. of antihypertensive medications used, No. (%) | |
| 0 | 8 (33) |
| 1 | 13 (54) |
| 2 | 2 (8) |
| ≥3 | 1 (4) |
| Variable | Value |
|---|---|
| Age, mean, years | 53 |
| Male, No. (%) | 12 (50) |
| Race, No. (%) | |
| White | 21 (88) |
| Asian | 3 (12) |
| Black/African American | 0 |
| Other | 0 |
| Systolic BP, mean, mm Hg | 134 |
| Diastolic BP, mean, mm Hg | 85 |
| Diagnosis of hypertension, No. (%) | 16 (67) |
| BP >130/80 mm Hg | 18 (75) |
| No. of antihypertensive medications used, No. (%) | |
| 0 | 8 (33) |
| 1 | 13 (54) |
| 2 | 2 (8) |
| ≥3 | 1 (4) |
Blood pressure impact.
The majority of participants (96%) completed a 3-month in-person follow-up appointment. A total of 14 additional follow-up appointments were completed between the initial enrollment appointments and the 3-month follow-up appointments. Participant blood pressure outcomes are summarized in Figure 1. Of the 6 participants who had controlled blood pressures (ie, <130/80 mm Hg) at the enrollment appointment, 4 participants (67%) remained controlled at the 3-month follow-up appointment. The 2 participants who had uncontrolled blood pressure at the 3-month follow-up appointment despite having controlled blood pressure at the enrollment appointment were not consistently adherent to use of the device, which limited the ability of the pharmacists to remotely monitor these participants and identify whether their at-home blood pressure was truly trending up. Of the 18 participants who had a blood pressure greater than 130/80 mm Hg at the enrollment appointment, 7 participants (39%) achieved their blood pressure goal of less than 130/80 mm Hg at the 3-month follow-up appointment. The average systolic and diastolic blood pressure decreases in these 18 participants were 8.6 mm Hg and 7.8 mm Hg, respectively. One participant did not complete a follow-up appointment, and of the remaining 10 participants who still had a blood pressure of greater than 130/80 mmHg at the 3-month follow-up appointment, 2 had a history of white-coat hypertension and had controlled blood pressure based on the remote monitoring data.
Flow diagram of participant enrollment and blood pressure (BP) outcomes.
Pharmacist recommendations.
At month 3 of the program, the pharmacists made a total of 10 recommendations to participants’ primary care providers regarding changes to their antihypertensive medication therapy, and 7 of these recommendations were accepted. The types of recommendations made by the pharmacists included starting a new medication (3 of 4 recommendations were accepted), increasing the dose of a medication (3 of 4 recommendations accepted), or changing a medication either due to an adverse effect or to optimize medication therapy (1 of 2 recommendations accepted). Over the first 3 months of the program, an estimated 50 hours were spent on enrollment and follow-up of participants.
Adherence to device.
Data on the number of days on which blood pressure readings were reported by study participants at month 3 are summarized in Figure 2. Thirty-four percent of participants utilized the blood pressure monitoring device for greater than 15 days throughout the month, while 41% of participants utilized the device for 10 days or less throughout the month. The most common reasons for nonadherence included participants not having an established routine for checking blood pressure at home and traveling.
Number of days of documented blood pressure readings at month 3 of the remote monitoring program.
Discussion
The adoption of similar blood pressure monitoring programs will allow pharmacists to improve blood pressure outcomes for patients through the pharmacists’ role in combating clinical inertia and benefits of utilizing remote monitoring devices that have been demonstrated in previous literature. A study published in 2018 found when a clinical pharmacist reviewed a patient’s chart and provided recommendations to the provider prior to the patient’s hypertension appointment, therapy intensification occurred in 72% of patients, compared to 46% of patients who did not have a pharmacist make recommendations to the provider (P = 0.017).10 Similarly, throughout the employee hypertension monitoring program described, pharmacists were able to identify participants with undiagnosed hypertension and participants with uncontrolled hypertension. Pharmacists were able to work with the participants and collaborate with their primary care providers to make interventions to improve blood pressure control and advocate for antihypertensive therapy to be appropriately intensified. A study by Margolis13 reported that patients who utilized a remote blood pressure monitoring device and followed up via telephone with a pharmacist for hypertension management had significantly decreased systolic blood pressure compared to those who received usual care at 6 months (P < 0.001), and significantly more patients reached their blood pressure goal at 6 months (P < 0.0001). Another study, published in 2023, investigated the change in blood pressure between patients who were remotely monitored via an electronic cuff by a pharmacist and patients who utilized an electronic cuff but followed up with their primary care provider. The pharmacist followed up with patients via telehealth to make medication adjustments. The study found patients remotely managed by a pharmacist had a significant decrease in blood pressure (P = 0.01), while patients receiving usual care from their primary care provider did not (P = 0.45).4 The outcomes of the program described support utilizing remote blood pressure monitoring combined with pharmacist involvement in hypertension management and show a positive impact on reducing blood pressure and the achievement of blood pressure goals. Through the use of remote monitoring devices, pharmacists were able to focus efforts on participants who had uncontrolled hypertension while still monitoring participants with controlled hypertension.
Both participants and providers were already familiar with the ONU HealthWise Pharmacy, as many of the program participants filled their medications through the ONU HealthWise Pharmacy prior to the program. This allowed for seamless care to be provided through the program, from making a medication recommendation to the prescriber, to filling a prescription for the accepted recommendation, and following up with the participant regarding changes to medication therapy. While the program was implemented as part of an employee wellness program, the program can serve as a model for other pharmacies to implement a similar service outside of an employee wellness setting.
There were several challenges encountered through the development and implementation of the program. First, volunteers of the program largely consisted of participants who expressed interest after an email was distributed to all employees. Because participants were selected and opted in to the program, the participants likely were more motivated to improve their health and achieve their blood pressure goal, which was a source of potential bias in outcomes of the program. Not all participants were as adherent to use of the device as requested, which limited the ability of pharmacists to make interventions due to a lack of readings. While pharmacists sent text message reminders to participants to utilize the cuff 3 days per week and had discussions with participants at follow-up appointments to address reasons for nonadherence, device adherence is a continuing challenge for the program to overcome. Acceptance of pharmacist recommendations by primary care providers was reliant on close follow-up with provider offices to ensure the readings and recommendations were received and reviewed. Primary care providers did not have direct access to the online platform to view participant readings, so the pharmacists had to balance keeping the primary care providers informed while not overwhelming them with information. It was decided that participants were to inform the pharmacy when they had an appointment with their provider approaching, and the pharmacy would send their blood pressure readings to the primary care provider about 1 week prior to their scheduled appointment.
Future directions.
The program described is a pilot program to expand the employee services provided by ONU pharmacists. Based on the positive impact pharmacists were able to have on blood pressure control of employees throughout the first 3 months of the program, the goal is to continue to expand the number of participants, as there are more employees in need of pharmacy services for assistance with blood pressure control than are currently enrolled.
Due to a small number of program participants at the start of the program, it was manageable to conduct a weekly review of all participants’ blood pressure readings. As the program continues to grow, it may not be feasible or necessary to continue this frequent follow-up for all participants. As adjustments are made to the program, it is anticipated that the frequency at which readings are reviewed will become more participant-specific, with participants who are well controlled having their readings reviewed by the pharmacy at least monthly and participants who are not controlled or with adjustments to therapy having their readings reviewed by the pharmacy at least every 2 weeks.
Conclusion
A pharmacist-led employee wellness hypertension monitoring program utilized remote monitoring devices to improve employee blood pressure control through education on lifestyle modifications and medication recommendations to the participants’ primary care providers.
Data availability
The data underlying this article will be shared on reasonable request to the corresponding author.
Disclosures
This study was funded by a research grant from the ASHP Research and Education Foundation. The authors have declared no potential conflicts of interest.
Previous affiliations
At the time of the study Dr. Gushrowski was affiliated with Ohio Northern University HealthWise, Ada, OH.
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