Table 2 Adaptations to the Kaiser bundle prior to implementation

Patient registry

Patients with hypertension were identified quarterly using outpatient diagnostic codes, pharmacy data and hospitalization records from health plan databases, and diagnoses were verified through chart review audits of random samples of identified members

Development of an internal hypertension patient registry to facilitate provider performance feedback and panel management outreach to schedule patients with uncontrolled HTN for BP visits

Hypertension registry shared between CHCs and FBOs, using the Eureka platform. Participants enrolled in registry after active consent; identified through health record queries in CHCs and at FBO sponsored community events

Hypertension control reports

(Performance reports?)

Reports generated every 1–3 months for each medical center and distributed to their directors. Reports were also available for clinic leaders to generate when needed

Clinic-level reports, stratified by race, shared with clinic leaders monthly and available for clinic leaders to generate reports

Quarterly reports generated for each of the two CHCs and distributed to practice managers by the BP Champion and site PI. FBOs: Study-wide quarterly report focused on study enrollment and BP control

Evidence-based practice guideline

A four-step hypertension control algorithm was developed to aid clinicians

Partnered with nurse leaders to design a standardized BP measurement protocol

In collaboration with community partners, we will develop and distribute a simplified BP measurement protocol, per AHA guidelines, for use by CHCs, community health workers, and RMAs in FBOs

BP checks

Every 2–4 weeks, a medical assistant measured blood pressure and informed the primary care physician, who then directed treatment decisions and follow-up planning

BP check visits led by registered nurse and pharmacist staff

BP checks may be conducted by RMAs in non-healthcare settings and by nurses/medical assistants in the CHCs

Medication (treatment) guideline

Single-pill combination therapy (lisinopril-hydrochlorothiazide) incorporated into the regional guideline as being optional for initial treatment and recommended as a step two strategy

A simplified evidence-based treatment intensification protocol, modified to account for drug coverage and affordability, patient complexity, and clinical guidelines

We will develop and distribute a standardized treatment protocol, per AHA guidelines, for use by CHCs and community health workers focused on affordable single-pill combination therapies

Community resource referrals

Not specifically part of the bundle

Not specifically part of the bundle

Assessment of health-related social risks in Eureka; RMAs and project coordinators/CHC healthcare staff make and coordinate referrals to community-based resources for identified needs