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“Let’s Take a Deep Breath”: Managing Hypertension by Bridging the Clinic-Home Healthcare Gap

Independent Project Findings

By Harsh Sharma,  Neurobiology, Physiology, and Behavior, ’13

Author’s Note:

“I wrote this paper to share my independent project takeaways with everyone who is interested in, or a part of, the healthcare field. This project taught me a lot about what we can do to help our patients get the most out of the clinic they go to. As you gain experiences in the medical field, think about the services your organization offers and how you can use your skills to enhance those services to the next level!”

Background

My Community HealthCorps experience at LifeLong East Oakland, a federally qualified community health center, can be described as a tale of two halves. During the first half, I accompanied Brigitte Peltekof, LifeLong’s social worker, on home visits in the East Bay Area.

I slowly learned to conduct an entire home visit by observing Brigitte. This entailed asking patients about the different social determinants of health– housing, income, transportation, caregiver support, and psychosocial history, to name a few. We then used this information to help patients access the health and social services they needed.

Amassing patient interactions over 5 months gave me the confidence to pursue an independent project centered around home visits during the second half of my term. Without having worked out the details, I chose to make high blood pressure, or hypertension, the main focus of my project for several reasons. I primarily recognized its many eventual consequences, including damage to the arteries, brain aneurysm, and kidney failure. I hoped to raise awareness of high blood pressure’s life-threatening effects to our hypertensive patients.

My time at LifeLong leading up to the project also made me aware of the barriers patients face in coming to the clinic. By meeting patients where they live, my hope for this project was to make healthcare as accessible as possible for the patients involved.

Project Vision

I had three goals in mind when proposing this project. They are as follows:

  1. To provide the panel of patients with blood pressure cuffs and encourage a greater level of engagement in their well-being by monitoring their blood pressure and exercising daily.
  2. To instruct patients about no-cost, easy-to-perform breathing and energy exercises intended to elicit the relaxation response via regularly scheduled home and clinic visits.

Evidence by Stahl et al. 2015 (in “Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization”) states that “mind body interventions can reduce individual disease burden as well as the utilization of healthcare resources and are well suited to the changing healthcare environment.”

  1. To reduce patient’s’ blood pressure readings by encouraging the integration of

breathing and energy exercises into their daily lives.

Home Visits

I began visiting patients at the end of January once I received the shipment of blood pressure monitors and finalized an initial panel of patients. During our first visit, patients signed a consent form, were educated about the consequences of hypertension and guidelines for blood pressure numbers, and agreed to a list of responsibilities as part of their participation in this panel.

Patients were provided with a blood pressure log at the beginning of each subsequent home visit to enter the date, time, and blood pressure recording, along with comments about how they felt and if they had taken their medication that day. The previous blood pressure log was collected and uploaded into the patient’s medical record. I measured the patient’s blood pressure during the visit and recorded it in the log.

Home visits also entailed asking how the patient was doing. This led to conversations about the patient’s family, home environment, level of physical activity, concerns about a medication’s side effects, and more. Before leaving, I scheduled my next visit with the patients to increase the likelihood of maintaining regular visits.

This project’s initial focus was to parse out three breathing exercises during each home visit, so as to not frontload the patients with too much information at once. The breathing exercises are often utilized in yoga (including chair yoga), energy medicine, and meditation. Most patients discovered their blood pressure to be significantly lower after engaging in breathing exercises for 5 minutes. While some patients looked forward to learning a new set of breathing exercises during each home visit, some wished to focus their efforts on a select few.

Patients who, at first, had only been interested in learning additional breathing exercises also started to utilize me as a health coach. They wanted to know when their next doctor’s appointment was, how they could switch providers, whether they were taking their medication correctly, etc. They recognized the value of having someone from the clinic come to their home and took full advantage of my service. Some patients asked me to prepare a handout about diabetic neuropathy, come up with a week-long menu of health meals, help schedule a dentist appointment, and so on. Electronic versions of all handouts can be found at: http://tinyurl.com/HTNproject

As a result, these home visits took an unexpected but welcoming change. I was now indirectly addressing hypertension by helping patients with their other chronic conditions and overall well-being. Considering that most patients on the panel, and the community in general, are alone during the day time, having someone to talk to and listen to them became refreshingly therapeutic.

Patient Q & A’s

During my penultimate home visit, I asked each patient twelve questions about this project. Patient interviews were recorded and subsequently transcribed. Below is a paraphrased summary of the Q &A. You will find the questions and assortment of answers provided by the patients at the end of this paper.

Patient takeaways from this project included awareness about the importance of getting in a relaxed state of mind while taking their blood pressure. Deborah S. spoke of the stark difference between taking her blood pressure with the TV on and off. The latter allowed her to reach a more calm state, which resulted in a lower blood pressure reading. Jarvis J. reflected on the project as a life-changing experience that improved his other health conditions and uplifted his overall sense of well-being.

Patients provided insightful suggestions on how this project could be improved. One suggestion was to go on a walk instead of having home visits, so as to provide patients with a change of environment. Linda S. suggested holding a monthly group meeting at the clinic so panelists could engage with one another and exchange successes and challenges.

When asked about what advice she would give about blood pressure, Willie B. offered that blood pressure plays a significant role in affecting quality of life as one ages. Kris D. advised individuals to focus on taking care of themselves and keeping stress to a minimum. She admitted that making time for herself is something she needs to work on, but she recognizes how important it is in maintaining a healthy blood pressure.

Most patients resoundingly wished their healthcare provider to know that this program should continue. I worked with patients who predominantly spend their time at home, alone. Home visits gave them an opportunity to socialize and talk to someone, which is powerfully therapeutic in itself.

Reflections

I have been deeply humbled by the patients I have had the honor of serving. I admire my patients’ courage to own up to their health conditions and their willpower to commit to improving their health. I am moved by their openness to invite a stranger into their home again and again. Their vulnerability in sharing their fears, hopes, strengths, and successes inspires me. I have seen them grow into individuals who are more invested in taking care of their health and more knowledgeable about how to do so. By spending countless hours with them, I have become a better listener and patient advocate. I have experienced tremendous personal growth from hearing their incredible stories and helping them navigate through our healthcare system. I will carry the lessons I have learned from them throughout my medical career and beyond. I want to thank them for their hospitality, their time, and their willingness to change.

By experiencing patients’ inquisitive nature toward health-related topics and their need for assistance with navigating our healthcare system (making appointments, asking about referrals, etc.), I am convinced that this project should continue to exist.

Patients who have someone that they can spend their time with in the community, without any significant time restrictions, receive a rich layer of individualized patient care and experience greater patient satisfaction. They are also more likely to utilize their clinic’s services and be intrinsically motivated to pursue a better state of health.

Moving Forward

Based on the feedback from patients and agreement from LifeLong staff, I firmly recommend that a project like this become a commonplace feature of our clinics. Having Health Coach Volunteers would allow clinics to do just that. Better yet, all parties involved would benefit from such a program.

Volunteers, who would mostly be future or concurrent applicants to medical and other health professional schools, would stand to gain an unparalleled experience working with the underserved on a 1-on-1 basis. They would have the opportunity to identify a patient panel and follow it over several months. Health coach volunteers would create patient education materials, shadow social workers and providers, and gain a strong letter of recommendation. Not only will their experience give them an edge in their applications to professional or graduate schools, but it also will deepen their understanding of how healthcare works and increase their maturity as they continue on their path to becoming future healthcare professionals.

If you would like to implement a similar program at your clinic, do not hesitate to contact me at sharmaharsh91@gmail.com. I will be happy to provide you with the appropriate resources.


Extended Patient Q & A’s

  1. What has motivated you to be a part of this project?

“Blood pressure issues. Newly discovered BP [blood pressure] issues.” –Susan B.

  1. Before I started doing home/clinic visits, what did you think this project would be like?

“I didn’t really know. I just, um, was like ‘hey, [they’re] just trying to see…’ I was really wanting to learn things to help me de-stress my body and that was my main concern of how to get this blood pressure down. Because even though I went through a process of losing weight before, I still had high blood pressure. So, it wasn’t just my weight, it was also the stress levels that I carry in my body.” -Kris D.

  1. When I started doing home/clinic visits, how did these expectations change? Was it for the better or worse?

“It was for the better. I’ve noticed that my BP has gone down. Like, the last time I checked it was like 121/79, which was never, ever the case. And I think that has to do with the fact that I started eating more vegetables, and taking time to jot down my BP, be more careful in doing the breathing techniques as well…and turning off the TV while taking my BP. I think that’s #1. Because before I would do it with the TV on and be more in tune with that and I think because I take time to just relax, breathe, and not have anything interfere helped.” -Deborah S.

  1. Now that the project is coming to a close, how would you reflect on it?

“A life-changing experience. With the way my BP was, it was just a matter of time before I had a stroke or…or something else could occur from it, but since I been in the program, all the testing that I’ve been doing for other things that I’ve been coming to the doctor for has just been beautiful. You know, I think my BP being kept at where it’s supposed to be kept at makes the other things work even properly without even me knowing it, since I’m not a doctor. But I can just feel the difference. You know, I’m not walking around with my head just feeling heavy. Like if you touch it, your head’s about ready to explode. You know, I was walking around like that for quite some time. And it was time for me to wake up and you guys woke me up to see that my life mattered.” -Jarvis J.

  1. How could this project have been better?

“Well, we could’ve started the walking earlier. You know, going for a walk when I visit, we could’ve started that earlier. But other than that, it’s…it’s great. But I think I like the out visit more than I do the in-home like, you know going out walking with you and then going over the things…because it’s just, I don’t know, you take it in better I think. Because when you’re in home, you’re just…it’s like okay, hurry up and finish. But walking the lake [Merritt] made it like, okay, you know, we gotta walk anyway, so why not talk and do, yeah.” -Deborah S.

“If we had did it in a…I don’t know…group would be all right to see what other people is do- ing. Sitting around, talking about what can be done better. I’d like to know if other people were benefiting, besides me with the program. If we got in a group, we could talk about it, and see what we could do better.” -Linda H.

  1. What would make it easier for you or other patients to be compliant?

“Be serious about it. Everything that I’ve done at the clinic, I’ve taken as seriously. And I realize that everything that happens there, which has been, you know… given to me, has been a help.” -Gloria R.

  1. If you had to give patients who are in your shoes advice about BP, what would you tell them?

“That eating actually is really…you know, eating the right stuff, eating vegetables and exercising has a lot to do with your BP, too. So taking time out to do that. And, just make sure you eat right, exercise, and do breathing techniques. I didn’t think the breathing techniques would work, but they do. They really put your mind at ease.” -Deborah S.

“I’d tell em it was very important for them to know what their BP is because that’s kind of determining what their quality of life is gonna be in the future.” -Willie ‘Delphine’ B.

“Pay attention. Pay very close attention because it’s something that can change, you know, without you being aware of it. That’s why they call BP the silent killer.” -Susan B.

“Don’t stress…don’t stress. Stress is a silent killer and I’ve been told that by a physician at LifeLong. Even though I’ve been told that and I try not to stress…I think once I get through my challenges of school and other things, I’m gonna really work harder on taking care of me. And I told that to my daughter and a friend that I wanted to take more time, um, taking care of me now. Because I’ve given my all to other things except for me, and I wanna make me feel better in the long run. I wanna feel better, I really do. Because stress is no joke. And then, on the 21st of May, my cousin died and, um…56 years old and he’s gone now. I know he was dealing with CHF so…life is short.” -Kris D.

  1. What were some challenges you faced with this project? With taking your BP?

“Getting the routine of getting it started and doing it every day” -Sharon E.

  1. What were some successes?

“Well, the biggest success is getting my BP under control to where I know the things that I ought to do and I know the things I should not do as far as the things I shouldn’t eat or how much of the things I shouldn’t eat. I should implement more fruits and vegetables, less fried foods, more baked foods or grilled foods. And cut out a lot of the pork and beef. And…I might hate myself for saying it…and the sweets. Every once in awhile brother, every once in awhile.” -Jarvis J.

“Having someone as an advocate for your health.” -Sharon E.

  1. What’s the most important thing you’ve learned during our time together? What are your takeaways?

“It’s, man, I’m thankful for…really, really [helped] me. From the starting, you know, I’m kind of, man, I was busy. Make a lot of money doing my job. See, now I know, money is nothing. Take care of myself and my family…you know, that’s the first priority. My kids, we used to have soda all the time in this house. They can drink soda once a while but I tell them, don’t bring any soda. You guys have to drink water.” -Toutai H.

  1. What would you like your provider to know about this project?

“That it will save lives. It will save people from having aneurysms, strokes, heart attacks. All they have to do is give the program a chance to work for them and once they give the program a chance to work for them, they will see the changes in their lives.” -Jarvis J.

“That it needs to continue. More people need to be made aware and have the advantage of being involved in it.” -Susan B.

“That this project should continue, if possible. If not by you, someone else come in. I think it should continue because it’s very important, like I said, for the patient to have that 1-on-1 with someone else besides the physician. Because sometimes when you go to your physician’s appointment, you’re basically being rushed and they’re not, you know, really listening or really concerned.” -Kris D.

“It’s a good program. They need to keep it. It helps to have someone come in and teach you things you don’t know nothing about like exercising, how to eat, how to stretch, how to breathe.” -Linda H.

“Most of us are seniors, and they have to have motivation to do something. And your visits and talking and stuff like that gives them company and helps motivate them.” -Sharon E.

  1. Will you continue to do the things you’ve learned from this project?

“Yes I will. Even after you guys are gone and the next group of young people come in, I will be a part of it.” -Jarvis J.

“Yes, absolutely. Including taking my blood pressure” -Susan B.

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