Telephone Outreach Is Associated With Improved Blood Pressure in Patients at an Urban Community Health Center

Abstract

Purpose:

Hypertension (HTN) disproportionately affects marginalized communities due to persistent healthcare disparities and socioeconomic barriers. Less than half of patients with HTN achieve blood pressure (BP) control, with Black Americans on antihypertensive medication experiencing lower rates of BP control (34.9%) compared to non-Hispanic Whites (45.0%). This pilot study evaluates the effectiveness of a telephone outreach intervention designed to improve BP control through self-management in a historically underserved population.

Major Findings:

This single-cohort, pre-post intervention study was conducted at a Federally Qualified Health Center (FQHC). Patients with severe hypertension were identified and contacted by trained student ambassadors (SAs). These SAs provided hypertension-specific health education, health goal-setting, guidance for self-monitoring blood pressure, and referrals to address health-related social needs (HRSN). During in-person classes, patients were educated on BP self-monitoring and goal setting regarding healthy lifestyle practices. Results from this study showed a reduction in SBP and DBP among engaged patients and improved hypertension knowledge.

Conclusion:

These findings suggest that telephone outreach, when combined with skill-based in-person education, can improve hypertension control in Black American populations.

Background

According to the 2017 Hypertension Clinical Practice Guidelines, hypertension is diagnosed when systolic blood pressure (SBP) is ≥130 mmHg or diastolic blood pressure (DBP) is ≥80 mmHg. ¹ In the US between 2017 and 2020, an estimated 46.7% of adults aged 20 years and older—equivalent to 122.4 million people—had hypertension. ²

Hypertension prevalence, outcomes, and access to care vary across racial and ethnic groups, with Black Americans experiencing the highest rates in the United States. Hypertension is more common in Black individuals, with 75% of Black individuals having hypertension before the age of 55 years compared to 55% of non-Hispanic White (NHW) men and 40% of NHW women. Additionally, Black men and women have higher mortality from stroke compared to NHW men and women. ³ Factors associated with these disparities in the literature include gaps in clinical care, socioeconomic factors, health related social needs (HRSN), awareness of blood pressure (BP), and individual physiologic factors. These findings reinforce the need to prioritize hypertension outreach in Black American communities, including Durham, North Carolina.

Multiple interventions have been implemented to address the higher rates of uncontrolled hypertension in the Black population. A review of 27 studies carried out between 1981 and 2006 found that health education in conjunction with individualized patient support, were linked with improvements in hypertension. Another review of community-based interventions targeting hypertension in Black people determined that successful initiatives involved out-of-office BP monitoring, novel settings for implementing hypertension control (like barbershops), and community health workers. ⁴

Additional evidence of the potential of community-based initiatives for hypertension control can be found in an intervention targeting socially disadvantaged Black patients at an urban primary care clinic. Assigning patients to a community health worker and providing them with BP cuffs was associated with improved BP control. ⁵ This study suggests a generalizable benefit to proactively reaching out to and engaging with patients, particularly perhaps in the context of clinics such as Federally Qualified Health Centers (FQHCs). ⁶

The purpose of this project was to reduce BP in patients identifying as Black at an urban FQHC. To achieve this broader goal, our specific aims were to increase patient engagement with primary care, knowledge of hypertension risks and management strategies, skills in self-monitoring abilities, and health related goal setting.

Methods

Sample and Setting

This prospective, single cohort, pre-post intervention study used a quality improvement (QI) approach to evaluate the reach and effectiveness of a community-based BP initiative. This study identified 333 individuals with uncontrolled hypertension (SBP ≥140 mmHg) using the last recorded blood pressure from a primary care visit at a FQHC in the U.S. This study was reviewed by the institution review board and approved as an exempt, QI initiative.

Measures

The primary outcome measure, pre- and post-blood pressure, was obtained from blood pressure measurements taken during clinic visits. Patient engagement was measured by number of calls completed with a SA and number of in-person classes attended. Hypertension knowledge was measured using a validated hypertension questionnaire. ⁷ To assess participants’ HRSN the “Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences” (PRAPARE) questionnaire was used. ⁸

Procedures

The intervention involved 3 structured telephone outreach calls, each designed with a specific objective to improve patient engagement, hypertension knowledge, and self-monitoring practices. In addition, in-person Hypertension Education Classes were held monthly at the FQHC. Throughout the outreach process, SAs documented whether patients answered calls and elected to participate, engaged with calls, requested a BP monitor, showed interest in attending an in-person class, or had additional questions. Participants were contacted via telephone by SAs, and those not initially reached were called up to 3 times to initiate contact.

The first call aimed to introduce the intervention, assess baseline BP monitor access, and administered a hypertension knowledge questionnaire. Participants without a BP monitor were invited to receive a free monitor and learn how to use it at a free Hypertension Education class. Call 2 reinforced proper BP measurement practices, reviewed the American Heart Association’s “Essential Eight” lifestyle changes for improving heart health, supported SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) goal setting^9,10 and screened for HRSN using PRAPARE. The third call focused on progress toward goals, reviewed recent BP readings, repeated the knowledge questionnaire, and followed up on prior HRSN referrals.

Monthly in-person hypertension education classes were held at the FQHC to reinforce self-monitoring skills, distribute BP monitors, discuss lifestyle modifications for BP control, and support SMART goal setting. Patients were invited to attend these classes through the telephone outreach calls. BP was measured at each class and low-sodium food alternatives were provided. Additionally, 2 “BP Blitz” events were held at the FQHC to serve patients unavailable at the usual monthly class time. This allowed patients to receive in-person hypertension education and connect with community resources to support their health.

Analysis Plan

Baseline participant characteristics for continuous variables were reported as means and standard deviations (SD) and frequencies and percentages for categorical variables. To assess for baseline differences that may explain non-response among those not reached by telephone, comparisons between participants reached and not reached by telephone calls were made using 2 tailed t-tests for continuous variables and Chi-Square test for categorical variables. Process measures were reported using counts and percentages for total number of calls attempted, number reached, number participating in program, number reporting a Self-Monitoring of Blood Pressure (SMBP) reading, and number completing >1, >2, or >3 calls.

Differences in BP before and after the intervention were evaluated using paired 2-tailed t-tests. Change in BP among those who participated in self-monitoring and those who did not was compared using 2-tailed t-tests for aggregated BPs in 2 independent groups.

Results

Patient Demographics

A total of 333 Black patients were identified as eligible for the intervention based on their last recorded blood pressure meeting the criteria for uncontrolled hypertension. The average age of participants was 58 years (SD = 10.7, 28-80 years). Gender distribution within the cohort was 52.3% female. In total, 570 call attempts were made to patients in the cohort.

Call response rates, the frequency of patients picking up and being able to speak with an SA over the phone, for those who completed the full intervention (n = 13) versus those who did not (n = 320) were 52.2% and 27.1%, respectively. Demographic characteristics and differences in BP did not differ significantly between groups (completer vs. non-completer).

Patient Engagement

In total, 3 attempts were made to reach out to each patient in the cohort. Among the 333 eligible patients, 115 were reached (engaged and completed Call 1), 40 completed Call 2, and 13 completed call 3. Of the 115 participants reached for Call 1, 18 declined to continue with calls. Post-intervention clinic visit BP data was available for 50 patients who had completed at least 1 call (Figure 1). Many (n = 61) participants reported access to BP cuffs at baseline while 36 reported not owning but wanting a BP monitor.

Figure 1.

Patient flow diagram.

SMART Goals

Patients created a total of 39 unique SMART goals. Of the 33 patients who reported SMART goals, 22 patients had accountability partners with whom they could share their goals. For reporting purposes these goals were categorized into exercise, smoking cessation, nutrition, blood pressure checks, and medication compliance (Figure 2). Exercise-related goals occurred with the greatest frequency among the participating population, with 20 patients reporting wanting to create or modify an exercise routine. Another common goal was improving dietary habits, as 9 patients reported nutrition-related behavioral change plans. The focus of these SMART goals aligned closely with the recommendations of the Essential 8 framework shared with patients by SAs.

Figure 2.

Specific measurable actionable relevant timely (SMART) goals.

Hypertension Knowledge Questionnaire

During Call 1, SAs gave patients the option to complete a Hypertension Knowledge Questionnaire as a pre-test to assess their understanding of hypertension, and during Call 3, patients had the opportunity to retake the same questionnaire. There was a modest improvement in hypertension knowledge; however, only 3 patients participated, limiting interpretability of the results.

In-Person Patient Engagement

In total, 170 patients engaged in 1 or more of the in-person event opportunities provided.

Patients’ Pre- and Post-Call Outreach Blood Pressure

Prior to the start of the telephone outreach intervention, the average SBP of the entire patient cohort (n = 333) was 162.51 mmHg (SD = 13.00), and the average diastolic BP was 90.75 mmHg (SD = 14.01). Post-call outreach blood pressures were pulled from patient office visits after the start date of the intervention period. Of the 115 patients engaged by telephone, only 50 patients had BP data available from an office visit after SA outreach. The average post-outreach SBP of the reached cohort with available data was 146.14 mmHg (SD = 21.41), and the average diastolic BP was 83.46 mmHg (SD = 12.57). For the same cohort of 50 patients, the average baseline SBP was 161.62 mmHg (SD = 12.27), and the average baseline diastolic BP was 86.18 mmHg (SD = 12.17; Figure 3). The telephone outreach intervention was associated with a significant reduction in SBP of −15.48 mmHg (CI = −22.40, −8.56, P < .001) and a non-significant reduction in DBP of 2.72 mmHg (Figure 3).

Figure 3.

Pre-post blood pressure (BP) results.

HRSN Screenings and Referrals

Of the 115 reached patients, 36 reported HRSN and 60 referrals were placed to address their needs. One referral was placed for each individual need, and 16 patients reported more than one need. Of the 36 patients, 14 were screened using the PRAPARE tool during Call 2.

In total, 7 patients reported needs related to food access, 11 related to housing and rent assistance, 8 related to financial difficulties, 11 related to medical access, 6 related to transportation, 14 related to provider access, 1 related to employment support, and 15 related to access to BP cuffs (Figure 4).

Figure 4.

Health related social needs (HRSN) and social determinants of health (SDOH).

Discussion

The findings of this study suggest that telephone outreach to patients receiving primary care at an FQHC is associated with a significant reduction in systolic BP over a 4-month period. Key factors that contributed to the success of the intervention include improved patient engagement and hypertension awareness, and enhanced self-monitoring and goal-setting skills. These results highlight the potential for telephone outreach to lower blood pressure in patients with uncontrolled hypertension.

This study builds on previous interventions by integrating skill-based education, a hybrid approach to patient engagement, and structured follow-ups. Unlike traditional BP monitoring programs, this model empowered patients through self-monitoring education and ongoing telephone outreach support. By integrating telephone outreach and in-person classes, the intervention provided accessible education and reinforced self-management techniques. While previous studies relied on patients having nurse or provider visits to get their BP checked, this intervention involved BP monitor distribution and instruction by trained student ambassadors (SAs) to teach patients how to use their BP cuffs.^11-14 This approach allowed patients to receive care outside of the traditional appointment structure, which often poses significant time, transportation, and cost constraints. In addition, since classes allowed multiple participants at once, patients were able to engage in cooperative learning, share experiences, and build skills together. While some struggled to consistently monitor and report their BP, the focus on skill development laid the foundation for long-term self-management.

Using SAs for telephone outreach provided greater flexibility than traditional care models, allowing calls outside of traditional work hours and scheduling based on patient availability. Conducting 3 calls with the same SA supported continuity, accountability, and adequate progress monitoring.

Additionally, patients were invited to community events organized in partnership with local organizations and educational institutions, which increased knowledge of available resources, fostered social support and peer-to-peer learning. Not only did these events further educate patients and connect them to resources outside of this intervention, but they also reconnected patients with their FQHC in a positive way and encouraged follow up care.

Findings from this study align with previous studies that have examined telephone outreach interventions for hypertension management. One consistent challenge across telephone outreach interventions is the high drop-off rate observed. For example, a 2023 study of a remote hypertension program during the COVID-19 pandemic found that in the pre-pandemic period, 244 out of 512 patients (47.7%) dropped out of the program before completing the intervention. ¹⁵ Similarly, in the post-pandemic period, 234 out of 477 patients (49.1%) dropped out, highlighting the common challenge of maintaining patient engagement. ¹⁵ Similarly, this current project also faced significant attrition, with a substantial number of patients failing to complete all 3 telephone calls and fully engage in SMBP tracking. The high drop-off rates across interventions suggest the need for additional strategies to sustain engagement in telephone outreach hypertension management programs.

Furthermore, similar to previous studies, while this intervention was successful in reducing blood pressure, the intervention itself was relatively short, as calls lasted for roughly 5 months. As a result, this intervention lacks information on long term results on blood pressure reduction and program sustainability. This short intervention time is reflected in a study conducted in 2022 aiming to evaluate the efficacy of telephone outreach to address hypertension control among Black men lasting only 9 months. ¹⁶ While patients who attended their follow-up appointments based on telephone outreach experienced a significant reduction in SBP and DBP there was no long-term follow-up past the 9-month mark. These findings underscore the importance of exploring follow-up interventions in order to better understand their potential for sustained BP control and long-term health benefits.

Limitations to the design of this intervention include the small number of participants, barriers to transportation for in-person sessions, restrictions to when classes could be offered and when phone calls were made to patients, and low rates of self-monitored BP that was reported. The small sample size of participants limits the generalizability of the findings. Efforts to reach patients via phone faced obstacles, including non-working phone numbers and the fact that many calls were made during business hours when patients were unavailable.

Adequate access to BP cuffs also presented a challenge. Patients were required to pick up BP cuffs from the FQHC, which hindered some patient’s ability to obtain them. Additionally, insufficient coordination for BP monitor distribution on the research team’s end hindered patient’s ability to receive their BP monitor in a timely manner.

Future research is needed to determine the long-term impact of a hybrid, skills-based intervention on reducing blood pressure in Black American patients. Future studies could focus on methods of improving participant engagement and retention by addressing previously mentioned barriers. Future interventions could also focus on increasing access to BP monitors for self-monitoring by streamlining distribution processes. Effectively integrating SMBP with clinic-based care is essential to ensuring equitable access to necessary resources for hypertension self-management.

Conclusion

Interventions such as telephone outreach, in-person clinician-led classes, and community outreach efforts are associated with blood pressure reduction. Participants who completed this intervention reported improved self-efficacy in managing their blood pressure, achieving personalized health goals through SMART planning, and addressing underlying HRSN with the support of clinic resources.

Despite limitations, the intervention’s association with decreased blood pressure suggests a hybrid telephone and in-person education model may be a scalable solution for improving hypertension control in underserved communities. Future research should focus on longitudinal follow-up to assess the durability of the program’s outcomes, investigate additional methods to mitigate engagement barriers, and evaluate the program’s cost-effectiveness. Expanding access to hybrid care models may play a crucial role in reducing disparities in hypertension management and improving health equity in underserved populations (Table 1).

Table 1.

Demographic Characteristics of the Cohort.

Patient characteristic	Participants (n = 115)*	Non-participants (n = 218)**
Age, average years, n	58.1 (10.7)	57 (10.9)
Sex, n (%)
Male	55 (47.8)	104 (47.7)
Female	60 (52.2)	114 (52.3)
Race/ethnicity, n (%)
Non-Hispanic Black	115 (100.0)	218 (100.0)

*

Participants: Patients who completed at least 1 call (n = 115).

**

Non-Participants: Patients who did not complete any calls (n = 218).