We sought to develop and pilot an intervention to improve blood pressure (BP) and other intermediate outcomes (hemoglobin A1c, low-density lipoprotein cholesterol) of diabetes in a low-income, ethnically diverse population. English- or Spanish-speaking primary care patients with BP ≥ 140/90 on 2 visits in the past 12 months and any level of A1c were randomized to usual care (n = 24) or intervention (n = 31). Home health nurses assessed self-management and medication adherence, and they performed health behavior counseling. Participants transmitted daily BP and glucose results using simple home telemetry units to the nurse coordinator; these results were then aggregated and transmitted weekly to primary care providers to facilitate intensified treatment. After controlling for baseline levels, a significantly larger proportion of the intervention group was at goal for BP (adjusted OR = 9.3, P = .006) and A1c (AOR = 4.3, P = .049), but not for low-density lipoprotein cholesterol (AOR = 1.1, P =.86). Clinicians made more BP medication changes in the intervention group compared to the control group (8.3 vs 3.8, approaching significance at P = .06). Self-reported medication adherence and self-care behaviors were not significantly improved. We successfully developed a telephone- and email-based collaboration between home health nurses and primary care clinicians to address poorly controlled hypertension in an ethnically diverse population. The intervention, combining enhanced feedback to patients and their primary care providers and individualized behavior change support by home health nurses, is effective for improving BP and glucose in this setting.
Keywords: diabetes mellitus; hypertension; primary care; telemonitoring; underserved populations.