Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA.
Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.
Curr Hypertens Rep. 2022 Aug;24(8):267-284. doi: 10.1007/s11906-022-01193-6. Epub 2022 May 10.
There is a growing evidence base describing population health approaches to improve blood pressure control. We reviewed emerging trends in hypertension population health management and present implementation considerations from an intervention called Team-supported, Electronic health record-leveraged, Active Management (TEAM). By doing so, we highlight the role of population health managers, practitioners who use population level data and to proactively engage at-risk patients, in improving blood pressure control.
Within a population health paradigm, we discuss telehealth-delivered approaches to equitably improve hypertension care delivery. Additionally, we explore implementation considerations and complementary features of team-based, telehealth-delivered, population health management. By leveraging the unique role and expertise of a population health manager as core member of team-based telehealth, health systems can implement a cost-effective and scalable intervention that addresses multi-level barriers to hypertension care delivery. We describe the literature of telehealth-based population health management for patients with hypertension. Using the TEAM intervention as a case study, we then present implementation considerations and intervention adaptations to integrate a population health manager within the health care team and effectively manage hypertension for a defined patient population. We emphasize practical considerations to inform implementation, scaling, and sustainability. We highlight future research directions to advance the field and support translational efforts in diverse clinical and community contexts.
越来越多的证据表明，人群健康方法可改善血压控制。我们综述了高血压人群健康管理的新趋势，并介绍了一项名为“团队支持、电子病历利用、主动管理（TEAM）”的干预措施的实施注意事项。通过这样做，我们强调了人群健康管理者的作用，这些管理者利用人群水平数据并积极接触高危患者，以改善血压控制。
在人群健康模式下，我们讨论了远程医疗提供的方法，以公平地改善高血压护理的提供。此外，我们还探讨了基于团队的远程医疗人群健康管理的实施注意事项和补充功能。通过利用人群健康管理者作为基于团队的远程医疗核心成员的独特角色和专业知识，卫生系统可以实施一种具有成本效益和可扩展性的干预措施，解决高血压护理提供的多层次障碍。我们描述了基于远程医疗的高血压人群健康管理文献。然后，我们使用 TEAM 干预作为案例研究，介绍了实施注意事项和干预措施的调整，以将人群健康管理者纳入医疗团队，并有效地为特定患者群体管理高血压。我们强调了实施、扩展和可持续性的实际考虑因素。我们强调了未来的研究方向，以推动该领域的发展，并在不同的临床和社区环境中支持转化研究。
