Feasibility and Methodology of a Pilot Free Blood Pressure Monitoring and Follow-Up Program at Two Free Clinics

Abstract

Background:

Hypertension affects approximately 1 in 2 adults in the US. Home blood pressure (BP) monitoring programs are effective in the diagnosis and management of hypertension. Free clinics serve as an integral safety net for millions of uninsured and economically disadvantaged patients in the US. The feasibility and effects of a free home BP monitoring and follow-up program in a free clinic setting is not well characterized.

Methods:

This was a prospective study of the implementation of a pilot BP monitoring and follow-up program between March 2021 and August 2023 at 2 free clinics in the San Francisco Bay Area. A total of 78 hypertensive patients were enrolled in the program and given a free BP monitor. We surveyed via telephone the change in systolic and diastolic BPs and BP monitor use and comfort at 3 weeks. Volunteers in clinic roles involved in the BP monitoring program were surveyed to assess their time spent and perceptions of the program.

Results:

Of the 78 patients, 37 provided responses to the 3-week survey. A total of 36 of 37 (97%) patients reported using their BP monitor. A total of 35 patients reported using it at least once a week (95%), with the majority reporting at least four uses a week (68%). A total of 36 patients (97%) planned on continuing to use their BP monitor. At 3 weeks, the mean systolic and diastolic BP changed by −6.40 mmHg (95% CI, −10.8 to −2.01 mmHg; P = .00577) and −2.72 mmHg (95% CI, −5.62 to 0.188 mmHg; P = .0657), respectively. The time commitment for this program ranged from 130 ± 51 min for program leaders to 16 ± 14 min per week for patient-facing roles. All volunteer roles (patient-facing, phone follow-up, program leaders) expressed that they had a clear understanding of their responsibilities in the program (median 4 on Likert scale, IQR 3-5).

Conclusion:

Home BP monitoring and follow-up is feasible to implement in free clinics, resulting in high rates of patient engagement among respondents. Our findings suggest that home BP monitoring and follow-up programs may be beneficial in vulnerable patient populations.

Keywords

hypertension blood pressure monitoring free clinics

Introduction

Free clinics provide America’s most underserved with a healthcare safety net. Altogether, over 1000 free clinics in the US serve approximately 2 million patients yearly.¹ By providing primary care, mental health support, and miscellaneous services such as social support at little to no cost, these clinics save US taxpayers approximately 9.6 billion dollars in emergency room costs.² Student-run free clinics are a part of this mission, serving over 140 000 patients annually who traditionally face barriers to healthcare access, such as unemployment, poverty, a lack of English proficiency, and non-citizenship.³

The prevalence of hypertension in the US is approximately 1 in 2 persons, and hypertension is the most common diagnosis at free clinics.^4,5 Hypertension is one of the most important risk factors for cardiovascular disease. In 2021, approximately 691 000 deaths were attributed to hypertension in the US.⁶ Healthcare reform estimates suggest that increased treatment of hypertension has the potential to prevent the most deaths among modifiable risk factors for disease, over treatment of hyperlipidemia and screening for cancers, and that each 10% increase in patients utilizing hypertension treatment can prevent an additional 14 000 deaths annually in the US.⁷ Nonetheless, only about 40% of patients on hypertension medications have their blood pressure (BP) below a mean systolic BP of 130 mmHg and a mean diastolic BP of 80 mmHg.⁸ Moreover, the lower rates of well-controlled hypertension and higher prevenance among non-Hispanic Blacks, Hispanics, low-income persons, and uninsured individuals contributes to the disproportionate incidence of hypertension-associated complications in these populations.⁸

Home BP monitoring has increasingly been promoted by national and international cardiovascular guidelines to provide a more accurate picture of a patient’s BP.⁹ Home BP monitoring addresses diagnostic challenges for hypertension management, including white-coat hypertension (elevated BPs in clinic but normal in other settings), masked hypertension (normal BPs in clinic but elevated in other settings), and measurement reproducibility.^10,11 Evidence from randomized trials finds that self-measured BP monitoring can reduce BP and improve BP control, emphasizing the need for regular at-home monitoring.⁹ These results highlight the importance of at-home BP monitoring and follow-up. However, such a program has not been well characterized in a free-clinic setting.

Free clinics face unique challenges to hypertension management, including creating programs to monitor patients’ BPs, because of their patient population, structure, and staffing. Due to a lack of long-term healthcare services, uninsured patients often present with limited knowledge of their BP history, making a hypertension diagnosis and treatment plan solely dependent on in-clinic measurements. For free clinics based on a transitional care model, which is common among volunteer-based free clinics, the limited and sometimes sporadic patient visits hampers efforts to track BP changes and make hypertension diagnoses. Beyond these hypertension-specific issues, student free clinics face obstacles recruiting sufficient volunteers and securing funding since there is no direct financial incentive to serve low-income uninsured patients.⁵ Additionally, the frequent turnover of student volunteers and leadership along with the transitional focus of many clinics makes long-term care difficult.³ Furthermore, the need to serve a patient population that primarily speaks a language other than English may affect the care provided during clinic and decrease rates of follow-up and referrals.¹² Consequently, it has been difficult to implement free BP monitoring and follow-up programs at free clinics, which may be particularly important for underserved populations lacking consistent access to healthcare.

Here we present a hypertension initiative for free clinics, the Home Medical Equipment Program (HMEP). HMEP is a home BP monitoring strategy amenable for implementation in a free clinic setting. HMEP standardizes the identification of potentially hypertensive patients, provides free BP monitors and BP education, and creates a framework for hypertension diagnosis and follow-up care in free clinics. Given the characteristics of the free clinic patient population (eg, infrequent visits, poor follow-up, predominantly non-English-speakers), the feasibility and utility of providing free BP monitors and follow-up remain uncertain, yet enhancing access to mechanisms for BP management may significantly address a critical public health need. We hypothesized that while it would be feasible to implement a long-term follow-up program in a free clinic setting, follow-up and BP monitor usage rates by patients would be low, especially when compared with non-free clinic settings.¹³ Here, we report the feasibility of HMEP by outlining the program’s protocol, patient follow-up response rates and survey responses, and volunteer survey responses on the clinic workload and perceptions of HMEP.

Methods

Study Population

This was a prospective study that took place at Arbor Free Clinic and Pacific Free Clinic (together called the Cardinal Free Clinics [CFCs]), the 2 constituent student-run free clinics affiliated with Stanford Medicine in the San Francisco Bay Area. Enrollment in HMEP began June 2021 and is ongoing, but the results reported herein are limited to responses as of August 2023. Appropriate research ethics board approval and informed consent were obtained.

The 2020 International Society of Hypertension Global Hypertension Practice Guidelines recommend BP readings ≥140/90 mmHg across 2 to 3 office visits as indicative of hypertension.¹⁴ Due to the inconsistency of patient follow-up in free clinics, we defined the eligibility criteria for HMEP as ≥140 mmHg systolic or ≥90 mmHg diastolic in a single visit, a history of hypertension, or use of hypertension medications. Patients with current ownership of a home BP monitor or those who planned on leaving the US within 3 months of their initial clinic visit were excluded from the study.

From November 2021 to August 2023, we screened 803 patients at the CFCs for hypertension risk or past diagnosis. Of the 165 identified as eligible, 78 patients were enrolled in HMEP. For the other 87 patients, the most common reasons for non-enrollment were an inability to reach them over the phone and prior ownership of a BP cuff (Figure 1). Of the 78 enrolled, 37 patients reached the 3-week time point and responded to our survey. Of the other 41 patients, 35 patients did not respond, and 6 patients left the country.

Figure 1.

Study cohort. Program cohort from November 2021 to August 2023.

Program Structure

The CFCs are student-run free clinics with most staffing roles being filled by non-compensated student and physician volunteers.¹⁵ A clinic visit begins with a student volunteer called a “patient health navigator,” who is responsible for obtaining vitals and guiding the patient throughout the clinic visit (Figure 2). The patient health navigator provides the intake information and vitals for the pre-clinical student (either an advanced undergraduate volunteer or medical student). The pre-clinical student performs the medical history and formulates an assessment and plan with the resident/fellow and attending. Necessary information on the patient’s next phases of care, such as primary care, prescription medication, labs, or social service referrals, is then indicated on a structured hand-off form and passed on to a “bridge-to-care” (B2C) student volunteer, who oversees referrals and follow-up information for the patient.

Figure 2.

Program overview. Overview of the CFCs workflow and relationships with the Home Medical Equipment Program (HMEP), HMEP task force roles, and timeline for HMEP calls. Patient health navigator (PHN) volunteers help obtain vitals in the clinic. Bridge-to-care (B2C) volunteers aid in referrals and, for HMEP, consent patients and provide them with the BP monitor. Community health worker (CHW) volunteers serve as the follow-up arm of HMEP and administer follow-up surveys at baseline, 3-week, and 3-month timepoints.

A task force within the CFCs was initiated in March 2021 to implement a BP monitoring and follow-up program at both Arbor Free Clinic and Pacific Free Clinic. We inserted HMEP at several points in the Cardinal Free Clinic workflow. First, training was provided for patient health navigators, including proper BP measuring technique and identifying cut-offs for HMEP eligibility. Second, additional questions pertinent to patients’ BP status were added to the referrals hand-off form, including questions about whether the patient has hypertension and if they have a BP monitor at home (see Supplemental Information). These answers were relayed to B2C volunteers who oversee referrals. B2C volunteers were trained to screen patients for HMEP eligibility based on information in the hand-off form. If the patient met eligibility criteria for HMEP, the patient was consented, provided education on how to use BP monitors and evaluate their readings, and given a BP monitor by the B2C volunteer at the end of their clinic visit. At the beginning of each week, HMEP task force members reviewed the electronic medical record of all patients seen during the prior week to identify any eligible patients who were not recruited. Patients not identified in clinic were consented by phone post clinic visit by the HMEP task force and sent a BP monitor via mail if they fulfilled enrollment criteria (Figure 2). To ensure consistency, all BP monitors provided were the A&D (UA-611) BP monitor (Tokyo, Japan). This decision was based on its automatic function and its published clinical validation.¹⁶

In addition to the core HMEP task force in charge of implementation, “community health workers” CHWs were recruited from the CFC volunteer pool quarterly to conduct patient follow-up calls for BP monitoring and surveys via telephone. Each quarter, the HMEP task force provided an hour-long training session to new volunteers. In addition, CHWs were provided written protocols, video demonstrations, and the opportunity to practice survey calls in groups. Each CHW indicated their desired patient workload quarterly, enabling long-term but flexible commitment. CHWs were assigned to the same patients for the entire duration of the program, given patients speaking the same language (where available), and given patient assignments weekly. The few CHWs who were assigned to patients speaking a different language used the Stanford Medicine interpreter telephone line.

Survey Design

HMEP included 3 surveys: a baseline survey administered within 1 week after the original clinic visit or consent call, a 3-week survey, and a 3-month survey. All survey questions are provided in Supplemental Information. CHWs were instructed to call patients at least 4 to 5 times, leave a voicemail, and send an email if patients did not respond.

The baseline call provides instruction to the patient on how and how often to measure their BP. In addition, for the baseline and 3-month calls, CHWs obtained BP measurements and answers to a questionnaire on Patient Activation Measures,¹⁷ medication adherence,²⁰ and physical activity^18,19 (see Supplemental Information) via telephone. The Patient Activation Measures is composed of a 13-question patient actualization metric survey on a five-point Likert scale that evaluates the patient’s knowledge and agency over their healthcare.¹⁷ The Likert scale ranged from 1 being strongly disagree, 3 being neutral, and 5 being strongly agree.

The 3-week call and 3-month call ask for the patient’s 5 most recent BP readings, BP monitor usage frequency and comfort, and self-perceived improvement in their BP management. If their BP readings were consistently over 135/85 mmHg, patients were scheduled for a phone follow-up appointment where BP medications are started or titrated.

Preliminary results for 3-week BP monitor usage frequency and comfort and self-perceived improvement in their BP management are reported in this article. The number of patients reaching the 3-month call that would indicate changes in Patient Activation Measures, medication adherence, and physical activity remain limited, hence the 3-week timepoint was used.

All clinic staff involved with HMEP responded to a questionnaire that assessed the number of minutes spent on HMEP along with the stress of being involved in the program and clarity of the program expectations on a five-point Likert scale. Follow-up questions pertaining to each clinic role (eg, for our B2C volunteers, how many additional in-clinic minutes did HMEP require of them) were also included and assessed on a five-point Likert scale.

Statistics

Variables are presented as mean ± standard deviation (SD) for normally distributed variables or median and 25th to 75th percentiles (Q1-Q3) for non-normally distributed variables. Normally and non-normally distributed continuous variables were compared with Welch’s t-test (unequal variance) or the Mann-Whitney U test, respectively, except for the baseline versus 3-week BP data that were compared with a paired samples t-test. Chi-square tests were used to evaluate significance in categorical variables. A 2-sided P-value < .05 was considered statistically significant. All statistical analyses were performed using SciPy (Python).

Results

The demographics and baseline characteristics (gender, age, language, country, and zip code median income) for our patients are shown in Table 1, categorized by all CFC patients, patients who met our eligibility criteria for hypertension, and those enrolled into HMEP. There were no significant differences between all CFC patients and hypertensive patients in sex, county, or zip code median income. We were unable to make any conclusions about language since 42.5% of CFC patients do not have a language listed. Using BP measurements taken in clinic, for the patients screened as eligible, the mean systolic BP was 147.5 mmHg (95% CI, 144.5-150.5 mmHg) and mean diastolic BP was 86.4 mmHg (95% CI, 84.3-88.5 mmHg) versus a mean systolic of 147.7 mmHg (95% CI, 143.2-152.2 mmHg) and mean diastolic of 88.0 mmHg (95% CI, 84.7-91.2 mmHg) for those enrolled in the study. The differences between eligible and enrolled patients for their systolic and diastolic BPs were not statistically significant (P = .928 and P = .419, respectively). Compared to the general CFC patient population that had a mean systolic of 129.5 mmHg (95% CI, 127.8-131.1 mmHg) and mean diastolic of 78.4 mmHg (95% CI, 77.5-79.4 mmHg), both the eligible and enrolled patient groups had statistically significant higher systolic and diastolic BPs (P = 1.63e−21, P = 8.12e−11, P = 1.89e−11, and P = 1.84e−07 for all eligible systolic, all eligible diastolic, all enrolled systolic, and all enrolled diastolic compared with the general CFC patient population, respectively; Figure 3).

Table 1.

Patient Demographics.

Demographic information		CFC patients(n = 803)	HTN risk(n = 165)	Enrolled(n = 78)	CFC versus HTN risk patients	HTN risk versus enrolled patients
Gender (count, %)	Female	398 (49.6)	78 (47.3)	38 (48.7)	Chi-square test of Independent P values:
	Male	315 (39.2)	75 (45.4)	36 (46.2)	Chi-square test of Independent P values:
	Not reported	90 (11.2)	12 (7.3)	4 (5.1)	.176	.819
Age (years)	Q1	42	50	47	Mann-Whitney U-test P values:
	Median	58	61	59	Mann-Whitney U-test P values:
	Q3	66	69	70	.000475	.348
Language (count, %)	Mandarin	177 (22)	48 (29.1)	18 (23.1)	Chi-square test of Independent P values:
	English	138 (17.2)	69 (41.8)	37 (47.4)
	Spanish	97 (12.1)	22 (13.3)	14 (18)
	Other	50 (6.2)	24 (14.5)	9 (11.5)	5.16 × 10⁻²⁵	.533
	Not reported	341 (42.5)	2 (1.2)	0 (0)	5.16 × 10⁻²⁵	.533
County (count, %)	Santa Clara	493 (61.4)	104 (63)	50 (64.1)	Chi-square test of Independent P values:
	San Mateo	104 (13.0)	16 (9.7)	9 (11.5)
	Alameda	55 (6.8)	14 (8.5)	9 (11.5)
	Other	32 (4)	7 (4.2)	4 (5.1)	.778	.590
	Not reported	119 (14.8)	24 (14.5)	6 (7.7)	.778	.590
Zip Code Median Income ($)	Mean	95 000	90 000	87 000	Welch’s T-test P values:
Zip Code Median Income ($)	SD	25 000	26 000	24 000	.451	.434

Comparison of patient demographics between all CFC patients, those eligible for HMEP (hypertension [HTN] risk), and those enrolled in the study. Gender, age, language, country of residence, and zip code median income reported as above. The language difference between Cardinal Free Clinic (CFC) patients and HTN risk/enrolled patients is driven primarily by a high percentage of non-reporting of language in the electronic medical record compared to HMEP records.

Figure 3.

Patient in-clinic BP. BP of all CFC patients, those screened as eligible for HMEP (hypertension [HTN] risk), and those enrolled in HMEP (enrolled) are shown. These BP readings were recorded in the clinic for all patients, where available (n = 623, n = 160, and n = 75 from left to right). No statistically significant differences in BP were noted between the eligible and enrolled patients (P = .928 and P = .419 by Welch’s t-test for systolic and diastolic BP, respectively). Difference between all CFC patients and both the eligible and enrolled patients is statistically significant (P = 1.63e−21, P = 8.12e−11, P = 1.89e−11, and P = 1.84e−07 for all eligible systolic, all eligible diastolic, all enrolled systolic, and all enrolled diastolic vs the general CFC population; P < .001 indicated by ***).

At the 3-week time point, patients report how often they used their BP monitor, if they found it helpful, and if they plan to continue to use it. A total of 37 patients who reached the 3-week timepoint responded to our survey. Of the 37, 36 (97%) reported using their monitor (Table 2) with 15 of 37 (41%) reporting using it more than 7 times a week and 10 of 37 (27%) reporting using it 4 to 7 times a week. A total of 34 of 36 patients (94%) of the patients using their BP monitor reported that their self-monitoring assisted them in managing their BP (Table 2). All 36 patients who reported using their BP monitor planned to continue to use it.

Table 2.

BP Monitor Usage.

Statement/question		Participant responses(n = 37)
Do/did you use your BP cuff?	Yes	36 (97.3%)
Do/did you use your BP cuff?	No	1 (2.7%)
How often did you use your BP cuff?	Less than once per week	1 (2.8%)
	1 to 3 time per week	10 (27.8%)
	4 to 7 times per week	10 (27.8%)
	More than7 times per week	15 (41.6%)
Did you find self-monitoring your BP with your BP cuff helpful for managing your blood pressure?	Yes	34 (94.4)
	No	2 (5.6%)
Do you plan to use your BP cuff?	Yes	36 (97.3%)
Do you plan to use your BP cuff?	No	1 (2.7%)

BP monitor usage statistics from the 3-week home medical equipment program survey. The second and third questions were only asked to participants who answered yes to the first question.

Additionally, we assessed for changes in patient’s BPs between the baseline and 3-week call (Figure 4). Of the 37 patients who responded to both calls, only 30 reported their BP at both timepoints and were included in this analysis. Mean systolic and diastolic BP changed by −6.40 mmHg (95% CI, −10.8 to −2.01 mmHg; P = .00577) and −2.72 mmHg (95% CI, −5.62 to 0.188 mmHg; P = .0657), respectively, although only the decrease in systolic BP was statistically significant (P = .00577 and P = .0657 for systolic and diastolic BP, respectively; Figure 4).

Figure 4.

Baseline versus 3 week BP. BP of HMEP patients from the baseline and 3-week calls are compared. These reading were reported by the patient over the phone to CHW volunteers. Only patients who provided both baseline and 3-week data are shown (n = 30). Reported p values are from paired t-test (P = .00577 for systolic BPs and P = .0657 for diastolic BPs; P < .05 indicated by *).

To assess the impact of HMEP on clinic and volunteer workload, we surveyed the time spent, clarity, and stress levels caused by HMEP on all present and former HMEP task force members, B2C, and CHW volunteers (Table 3). As expected, HMEP task force members had the highest time commitment at 130 ± 51 min per week, while B2C volunteers spent 16 ± 14 min per week and CHW volunteers dedicated 31 ± 23 min. B2C volunteers noted that the weekly in-clinic time burden was 16 ± 14 min. The median stress for each group falls at or below 3 on a 5-point Likert scale, and all groups of volunteers reported a relatively high clarity and understanding of their responsibilities in the HMEP program (Table 3).

Table 3.

HMEP Volunteer Feasibility Survey Responses.

Statement/question		HMEP TF(n = 5)	B2C(n = 20)	CHW(n = 25)	All(n = 50)
How much time do you spend on HMEP within any given week? (minutes)	Mean	130.0	16.1	31.1	35.0
	SD	51.0	14.0	22.8	40.2
How stressful or overwhelming has HMEP been? (Likert)	Q1	3	1	2	1.25
	Median	3	2	2	2
	Q3	3	2.25	3	3
My responsibilities as a X are clear, and I have the necessary resources to perform my responsibilities. (Likert)	Q1	5	3	4	4
	Median	5	4	4	4
	Q3	5	5	5	5

Abbreviations: HMEP, home medical equipment program; TF, task force; B2C, bridge-to-care; CHW, community health worker.

Responses to the HMEP Feasibility Survey from HMEP task force members, bridge-to-care volunteers, and community health workers on their time commitment, stress levels, and role responsibilities.

Regarding the clinic workflow, B2C volunteers indicated that they felt competent in identifying HMEP eligible patients (4 [IQR, 4-5]) and that the HMEP referral process is easy to follow (4 [IQR, 4-5]). Additionally, B2C volunteers agreed they have the capacity to refer patients despite the other time constraints present in the clinic (3.5 [IQR, 3-5]; Table S1).

For follow-up calls, CHW volunteers reported that the average call takes 27 ± 17 min, and on a Likert scale, reported neutral feelings toward the statement that they can reach most patients within 3 calls (Table S2). Given that over half of our patients do not use English as a primary language (Table 1), we also assessed the impact of interpretation services on our CHW volunteers. They reported feeling neutral toward agreeing that translation services do not impact the quality of the call (Table S2).

Discussion

In this prospective study at 2 free clinics, we assessed the feasibility of implementing a free home BP monitoring program in a patient population that is primarily uninsured, economically disadvantaged, and speaks a language other than English. We show that almost all patients (97%) who reached and responded to the 3-week survey used their BP monitor at least once a week, self-reported that the monitor was useful for their own BP management, and planned to continue to use. We observed a significant decrease in patients’ systolic BP but not diastolic BP between the baseline and 3-week timepoint. Moreover, the impact of HMEP on clinic workflow was relatively minimal, caused low stress, and the program goals and technicalities were clear and understandable for all volunteers involved. These results are especially relevant for B2C volunteers whose HMEP responsibilities fall within clinic hours. Follow-up calls for monitoring patient BPs and asking survey questions averaged 27 min. However, many of the questions asked during the follow-up calls are ancillary for HMEP and can be removed (see Supplemental Information) to further reduce the burden on clinic volunteers. We expect calls to be under 10 min without these questions. Further evidence of the relevance of providing BP monitors to free clinic patients is given by patients’ lack of BP monitors at home: of the 120 patients eligible for the program who gave a response, only 25 already had home BP monitors (21%).

To the best of our knowledge, this is the first reported free BP monitor and follow-up program in a free clinic setting. A common theme among free clinics is their reliance on both student and physician volunteers, which in our experience has both challenges and benefits. Challenges implementing HMEP include the need for repeated and separate trainings and reminders for different in-clinic roles at the CFCs, operating around volunteer schedules for follow-up calls, and coordinating smooth handoffs between clinic teams to ensure patients’ data is both gathered and acted upon. Benefits of free clinics include a large pool of HMEP aides for follow-up BP monitoring, who frequently have more time to answer questions that would otherwise be unfeasible in other clinic contexts. The increased pool of volunteers relative to most non-free clinic settings also allows more patients to be enrolled and tracked at any given time. Given these free clinic characteristics, it has been our experience that a focused task force that solves day-to-day complications of BP monitoring ensures patients are not left behind. This is particularly important for patients who already have decreased trust in the medical system such as those served by free clinics.²⁰

It is also worth noting that longer-term follow-up, particularly for student-run free clinics that commonly aim to provide transitional care, is often lacking.²¹ An interesting benefit of longer-term follow-up of our patients through HMEP is that the program provides an alternative avenue for clinic contact and follow-up. While the CFCs provide 3-week phone follow-up for all patients, primarily to verify the status of primary care referrals, ultimate referral success is often unknown at 3-weeks. Therefore, although not the primary goal of our CHWs, HMEP has been helpful for the CFCs to connect our patients with additional resources and provide them with new referrals if prior referrals were unsuccessful. In addition to providing BP monitors for hypertensive patients, future additions to the program may include diabetic patients (eg, home blood glucose monitoring) and additional opportunities for patient-specific medical education.²²

The decrease in systolic BP at 3 weeks is intriguing and likely represents a change in patient behavior, such as medication adherence. For the CFCs, hypertension medications are unlikely to be started or titrated after a single clinic visit, in line with hypertension guidelines,¹⁰ and so the improvement in systolic BP is unlikely to be attributed to this. Our observed changes in BPs are smaller in magnitude than those observed by other studies, in line with the short duration of our follow-up period.²³ We currently lack sufficient data to make conclusions at the 3-month timepoint that would reflect a more persistent change in BP. Future work may involve a detailed analysis of BP trajectory after the initial clinic visit, including how often medications were started or titrated during this period.

This study has several limitations stemming from the challenges reaching our patient population. First, study enrollment was relatively low considering that only 78 patients were enrolled out of 165 eligible patients, raising the possibility of sampling bias. However, baseline characteristics were not significantly different between eligible and enrolled patients. Indeed, the most common reason for non-enrollment was an inability to contact patients over the phone for consent. Although we were optimistic that volunteers during clinic would be able to identify and enroll all eligible patients with hypertension, in practice the revolving team of student volunteers meant that many HMEP eligible patients were not enrolled during clinic. Other limitations include the fact we did not systematically track whether patients were consented in the clinic or over the phone. Since a patient receives in-person training for using the BP monitor if they were seen in clinic, patients seen in clinic may have had a larger benefit from the program. Another limitation is only 37 patients reached and responded to the 3-week call. There is patient dropout at each stage of the follow-up process due to an inability to reach patients via telephone or due to patients leaving the US. The CHWs attempted to call a patient 4 to 5 time at different times during the week and were instructed to leave a voicemail and email before deciding that a patient cannot be reached. To contextualize our 3-week follow-up rate of 47%, a survey of faculty from 21 student-run free clinics indicates that their patients always complete referrals only 39% of the time but that test results are usually (45%) or always (55%) communicated with patients.²⁴ The difficulty in reaching patients even after repeated calls demonstrates the challenges of consistent communication and difficulty following-up with an underserved and uninsured patient population, as reported by other authors.¹² One potential solution could involve scheduling all calls in advance during clinic. Finally, HMEP or any similar program does require a financial investment of the cost of the BP monitor, which is around $40. Given the high BP monitor usage rate and the positive feedback from patients, we find this cost a worthwhile investment in patient empowerment but recognize that it may be prohibitive for other free clinics.

Here, we find that that home BP monitoring and follow-up in a free clinic population enables greater self-reported patient autonomy, has high rates of patient engagement among respondents, and is associated with improvements in systolic BP. Moreover, we find that a program such as HMEP was feasible to implement across 2 free clinics in terms of time spent and staffing requirements and was well-received by volunteers. We find these results indicative of the potential for home BP monitoring and follow-up to improve community health in vulnerable populations with inconsistent or sporadic access to healthcare. We anticipate that free BP monitoring and follow-up programs, if implemented at scale at other free clinics or in settings with similar patient populations, may greatly improve the cardiovascular health of the most underserved in our communities. We continue to evaluate patients enrolled in HMEP to determine the long-term effects of increased access to home BP monitors, follow-up, and contact with clinic staff in a free clinic setting.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319241278836 – Supplemental material for Feasibility and Methodology of a Pilot Free Blood Pressure Monitoring and Follow-Up Program at Two Free Clinics

Supplemental material, sj-docx-1-jpc-10.1177_21501319241278836 for Feasibility and Methodology of a Pilot Free Blood Pressure Monitoring and Follow-Up Program at Two Free Clinics by Georgios Mikos, Brian Yu, Jessica Balbin, Laisha Martinez-Reyes, Jonathan M. Tang, Brandon Nguyen Lieu, Edward Tran, Athena Xue, Jiwoo Lee, Neil Wary, Camryn Franke, Nicholas Panyanouvong, Melody J. Chaclan, Tony H. Chang, Crystal Chen, Michaela Y. Guo, Kelly Harvell, Rose Horan, Nicole A. Johnson, Audrey Kim, Eric Liu, Linda Liu, Pablo Nuñez-Perez, Madison Quig, Anushka Sanyal, Krishna Sharma, Iris Wang, Kelly Wang, Amy Filsoof, Mina Charon, Tamara Montacute and Baldeep Singh in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

The authors would like to thank the following CFC volunteers for their contributions: Nour Mary Aissaoui, Alvaro Bermudez-Canete, Danna Valentina Chacon, Aaron Chai, Brett Chy, Cameron Ehsan, Joyce Essuman, Gisselle Gonzalez-Perez, Robert Igbokwe, Emma Louise Jaeger, Tim Jing, Lenae Joe, Jaeah Kim, Bennett M. Liu, Viraj Mehta, Quennie Nguyen, Sofia Pesantez, Tiffany Sanchez Ramirez, Madeleine T. Salem, Katy Shin, Landon Swopes, Anita Taft, Tuananh Dinh Tran, Jennifer Wang, Daphne Lan Yu, Jingyu Zhang

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors thank Stanford Medicine and the Cardinal Free Clinics for their financial support.

ORCID iDs

Georgios Mikos

Brian Yu

Edward Tran

Michaela Y. Guo

Kelly Harvell

Kelly Wang

Supplemental Material

Supplemental material for this article is available online.

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