Good afternoon, and thank you so much for having me. I appreciate the moderators for the invitation and happy to talk with you a little bit about what we do in our community-based hospital. All right, so when I was a fellow, I grew up in the era of the JNC-7 guidelines, which really angered me, and I, at that point, decided to sort of devote my dedication towards hypertension for many of the reasons that have already been said, right? If you look at what makes the biggest impact and where you can make an impact with the least amount of money, it lands on hypertension, and so when I came to Cone, I started with doing an assessment of the landscape, and what I realized was that probably like a lot of your institutions, there was suboptimal control of hypertension, right, and not even to mention that there were differences based on race and age and gender. Other things that I noticed was there was a wide variation in the strategies and ways hypertension was being managed. I saw that it wasn't even clear who was supposed to be managing hypertension, right? Is it primary care? Is it cardiology? Is it nephrology? And the end result means it's nobody, and then I decided to sort of look at the social determinants of health and saw that, one, we weren't even really assessing them fully, and two, when we did, the interventions on them were not very robust or documented in any way that we could truly assess their efficacy. Other things that we saw were, you know, we all say diet and exercise, but the true interventions for lifestyle management were not ideal, and that there was not really a center to send truly refractory patients for hypertension, and so I saw this as an area to intervene. Another thing that I've now learned about why to develop a hypertension center is that it really does position you well to potential opportunities for clinical research in this area. So the first thing that I had to do was figure out how I was going to buy my time, right? So I'm not in academics, and it takes time to develop these things, and so I did a stakeholder analysis and realized that the first thing we should do is start with the data. So you all know from everything that we've all said that nationally we do a terrible job of controlling hypertension. Fortunately, at Cone, we were a little bit better than average. We were at 68% controlled, so that's just to the 140 over 90 percent…140 over 90 millimeters of mercury, but that still was not good enough for me, and I'm sure not good enough for you all either. So I went to our system and presented them with this data and told them that what we could do by developing a hypertension center was to help reduce the unreimbursed and unnecessary admissions, help to grow our cardiology practice. I went to my partners and said, send me all those patients that you can't get to goal and that you're tired of seeing. I went to PCPs and said, whether I get them to goal or whether you get to them to goal, you get credit for the metrics either way, and that's going to help you, so send me these patients and I'll gladly send them back to you once they're controlled. I went to the ED and the hospitalist and said, hey, all those people that you say, oh, they were in pain and so their blood pressure was 160, can you just send them to me to make sure that it's actually okay once they're not in pain? And then ultimately what really bought my time was I went to Triad Health Network, which is our ACO, who is most aligned with the goal of reducing unnecessary admissions and improving the population, and they said, okay, we'll give you one year at 0.2 FTE, and that's how this was built. So the first thing that I wanted to do is I looked at the guidelines and said, what do I want every patient who walks in our door to experience? And it's guideline-based therapy, right? And so the first thing that we do is that we assess medication adherence. So we call the pharmacy up for anybody who's on 3Meds or more and make sure that they didn't last pick them up in 2021, which happens. Then we do an assessment of social determinants of health on every patient, and it sounds like it's onerous, but really my CNA does this while she rooms the patient. She documents it in Epic and it's done. We then have a social worker who's embedded in our clinic so that anyone who has needs, they can help with intervening on any of the needs that are identified, and we have a health coach. We call her a care guide, but what she does is one of the most important things. So she helps with stress management. She helps with smoking cessation. She helps with just helping people figure out what's one thing you can do to improve your hypertension management and your health. We partnered with a program through the YMCA called PREP where patients get a 12-week program where they get education in small group settings on diet and exercise in the first half, and in the second half, we actually make sure that they all exercise despite the fact that they have knee pain or shoulder pain. We find things that they can do. We do an assessment. You guys have all heard about the assessment of secondary causes. They do that in a very systematic way, and we've created medication algorithms to help improve adherence by using polypills, so reducing the number of the pill burden, and also being very attuned to cost-effectiveness of medications. Finally, we also have ambulatory blood pressure monitoring that was already discussed, and we try to automate this wherever possible. So speaking of automation, so as I said, in EPIC for our EMR, the social determinants of health tab, we just click through that, and then not only is it documented, but you can see there's also an SDOH intervention button where we can document the interventions that we have done so that we can make it, you know, as you mentioned, this is not profitable work on the front side, but if we can document the impact of our interventions, it makes it easier for us to obtain funding to continue these types of things. And then we also automated the secondary hypertension workup so that we don't forget while we're in there to make sure that we've checked for pheochromocytomas and hyperaldosteronism and that it automatically populates into our note for people who see the patients going forward. This is the algorithm. It's, sorry, not very legible here, but things that I do highlight in this are that pretty much everything on here is for $3 at Walmart. There are polypills wherever possible, and we have entrance points based on race, whether or not people are frail, and whether or not they have pregnancy potential. As mentioned, this is a team-based approach where we try to be as holistic as possible, and I 100% agree that our pharmacists are at the heart of what we do in our center. So here's a little bit about the outcomes of what we have seen so far. So we just started in 2020, but what you can see here is so based on whether patients have been through our doors 1, 2, 3, 4, etc. times, the blue line on the top shows what their initial blood pressures were, and the orange line below it shows their last documented blood pressure within the health system, so that may have been with me or anywhere else. On average, you can say roughly there's been about a 20-point drop in blood pressures, which the perfectionist in me looks at 138 over 81, and it still irks me, but I feel better knowing that just that 5- or 10-millimeter of mercury improvement we saw before makes huge impact on outcomes. So I just wanted to give you sort of the nuts and bolts of what we've done in our community-based practice, and the keys that I think that we've had to our success so far are creating that stakeholder alignment, assessing adherence and limiting pill burden wherever possible, evaluating for secondary causes and using a medication-based algorithm, and using technology to our advantage. And obviously, I've never even been to SCI before, but I completely see the alignment here where all the things that we do are the things that you need to do before these patients can come to Renal Denervation Center for that procedure, and so I think I can't highlight enough the importance of partnering with someone like me who loves hypertension and wants to help manage these patients for you in perpetuity. Thank you.

hypertension center

social determinants of health

medication adherence assessment

technology for automation

blood pressure control