Population Care Management and Team-Based Approach to Reduce Racial Disparities among African Americans/Blacks with Hypertension

The Permanente Journal
Rowena E BartolomeBernice Gould

Abstract

At Kaiser Permanente, national Equitable Care Health Outcomes (ECHO) Reports with a baseline measurement of 16 Healthcare Effectiveness Data and Information Set measures stratified by race and ethnicity showed a disparity of 8.1 percentage points in blood pressure (BP) control rates between African- American/black (black) and white members. The aims of this study were to describe a population care management team-based approach to improve BP control for large populations and to explain how a culturally tailored, patient-centered approach can address this racial disparity. These strategies were implemented through: 1) physician-led educational programs on treatment intensification, medication adherence, and consistent use of clinical practice guidelines; 2) building strong care teams by defining individual roles and responsibilities in hypertension management; 3) redesign of the care delivery system to expand access; and 4) programs on culturally tailored communication tools and self-management. At a physician practice level where 65% of patients with hypertension were black, BP control rates (< 140/90 mmHg) for blacks improved from 76.6% to 81.4%, and control rates for whites increased from 82.9% to 84.2%. The racial gap narrow...Continue Reading

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