B (2:42)

Let's pause there for a second because, wow, I mean, the level of depth that you all are able to go to is truly impressive. But bring this up, you know, to the 30,000 foot view level for a moment because I don't know how many of our listeners are familiar with the Durham community and specifically the role that Duke plays in that community. So can you give it just sort of the brief snapshot of when you're talking about, you know, over 40% of the Durham population, how many people are we really talking about? And when you're saying going into the community, what does that look like?

D (3:11)

I can pitch in here. Durham has about 300,000 people, and roughly, as Anna pointed out, we have a prevalence of hypertension of. About 42 to 48% of the people in this county have hypertension. About half of those are uncontrolled or unaware. The third issue, I would say, in Durham county is the disparity in care that we've seen and the prevalence, the higher prevalence and the higher mortality and comorbidity that is associated with this chronic illness in the black population, which that statistic is true throughout the South. And so we have a high proportion of minorities and underserved patients in Durham county, and we tend to focus on these first as the risk in this group is much higher than the risk in the average population overall. So given that we started there, the clinics and the specific areas in the community where we could be most effective in improving overall health for the community were those underserved, like safety net clinics. And so across the county, we have our federally qualified health center, which Anna mentioned. And my Copa, Dr. Holly Biola, is there leading the effort there. And we've also worked together with the Duke Safety net Clinic, the Duke Outpatient Clinic, as well as our broader population health clinics in the county. So though the work began at Lincoln, our federally qualified health center, we have reached out to try and scale the project across other areas in the community that represent underserved populations.

B (4:51)

Thank you so much for sharing that. You know, I moved to North Carolina 25 years ago, and in the other places I've lived, I never really had the level of appreciation that I have now for just how different a place like Durham county can look when you drive like eight minutes from. From the downtown core. Because Durham, you know, with 300,000 people, there's definitely a downtown core and there's some high rises and it's not, you know, like New York City is downtown, but it's definitely an inner city environment, but eight minutes away, you are in farm country. And so when you're talking about reaching the community, you are going from a very urban feel to a very rural feel quite quickly. And so I know that community health workers have played a huge role in how you all have addressed this work through the project around hypertension. Tell us a little bit more about the role that you all are finding community health workers playing in amplifying community outreach.

D (5:47)

We have a cohort of community health workers. The intent for that workforce is to really expand and extend the work that's done in a clinic, during a clinic visit with a primary care provider. The fact is that many of our people in the underserved area especially have so many social determinants, which Anna can expand on, that it's hard to fit the care that's needed within that short window of time of the visit. This project has served to really engage health professions students like Anna as patient navigators to partner with these community health workers and literally give everyone more time to be able to provide the care at the community level that we want to do. So Anna can expand on exactly what that looks like.

C (6:38)

I think, as she pointed out, there was this huge not gap that necessarily we realized, but this system that patients weren't necessarily getting the full time that they needed to, just with the limitations of the system. And so I think what really community health workers, and in our case students, were able to really fill that gap was kind of being able to take that time with patients when they had it. Our first call with patients and students made was just sitting down with them being like, are you interested in kind of learning more about what hypertension means or how we can kind of implement some lifestyle changes and can we do that on your time? I think that was just a really big portion of whether it was people that were working two to three jobs and only had availability at 8pm or 9pm I think that was kind of the really great gap that students could kind of fill is kind of making sure outside clinic hours, where can we sit and really impact and make a change. And then on top of that, really kind of making it really personalized with the education that we gave them, learning about the different things that they were kind of experiencing, what kind of struggles were specifically relevant to their lives. Whether that was, I'm struggling of trying to get groceries when I have to make sure to pick up my kids from preschool, or whether it's I'm taking care of two of my parents that are kind of based in the hospital and kind of making sure that we were able to insert little pieces of advice, whether it was hey, like how about we try to get 30 minutes, you know, walk to your parents house instead of necessarily being able to drive there and really kind of instill small changes that they can make and really be their personal cheerleader and kind of instill in these, these small changes that can really make such a big difference in their blood pressure and hypertension.

B (8:05)

I love that. Wouldn't we all benefit from having a personal cheerleader, especially when, when fighting, you know, a condition like hypertension, which is so seemingly innocuous because it's just a number on a machine. But we know that, that years and years and years of high blood pressure take its toll on nearly every organ system in the body. And again, being good project leads, I imagine you all are measuring countless kinds of metrics through this work. What is one measurable impact that you can tell us about through this engagement of community health workers and really extending their reach not only into patients homes but into community based settings as well?

C (8:40)

I think the big one was just the impact that we had on their blood pressure and then also just self management. I think within our intervention this past year we saw a average drop in the systolic blood pressure of those that participated of over 15 milligrams of mercury, which is just a really huge kind of drop when considering this intervention that took place. And I think another big one was this idea of self monitoring, kind of bringing the power to the patient, kind of being able to track with the free blood pressure cuffs that they were able to be provided as well as the social needs assessment was kind of really putting that power of health back in their hands and showing that community health intervention led can produce really meaningful clinical outcomes.

B (9:19)

Spectacular Brady anything you would add?

D (9:21)

The one thing I would add to that is the idea of the system integration that this project brings, whereby to your point, hypertension really is a chronic illness, that the long term outcome is what we're after. Reduction in stroke, reduction in chronic kidney disease and reduction in cardiovascular events. But those things happen so far from today's single measurement or even a couple of years worth of measurements of high blood pressure in an office visit, which is often mistakenly elevated anyway our real achievement. I feel like in addition to what Anna said about bringing the power to the patient to set their goals and really be able to be aware and to be responsible for changes and improvements in their health, we we also really are trying to effectively connect a patient to the primary care provider team, including the community Health worker and the community business organizations that help us serve patients outside of the formal system of healthcare delivery. These groups provide food, transportation assistance with housing and security and all the things that are real barriers for patients. Managing long term hypertension, solving for those things and tracking it as we have and making sure there's a closed loop on the referrals that happen allows us to really measure the impact of this kind of project on some of our really important community outcomes. But also the policy implications for this project which we're working on now with our North Carolina Department of Health and Human Services and trying to make sure that the opportunity for us to expand Healthy opportunities pilots from our Medicaid expansion initiative, trying to make sure that we have the evidence and the measurable outcomes to support new policies for expansion of those kinds of efforts in a community.

B (11:22)

Well, you all have certainly covered the waterfront. I mean clearly it takes a team and you've been able to connect not just the acute care clinical team, but the patient's family, community teams all together in this web in supporting patients. I'm curious, we've only got a minute or two left. If you had to give one piece of advice for healthcare team members in a community right now listening to this podcast who are just coming away from hearing your story and saying I gotta go do this tomorrow, what would your one piece of guidance be as they're preparing to take their first step?

D (11:57)

Our guidance would be communicate with your primary health care provider and let them know you're interested in joining our team as a patient expert in the hypertension management program.

B (12:08)

Outstanding. Anna, what if you were giving advice to a hospital who was hearing the story and they said I want to be just like this project that they're doing at Duke.

C (12:17)

I think it's just showing that it's possible to get intervention like this off the ground and it really can make a real big difference in patients lives. And so kind of putting a focus in community health workers and kind of connecting back that primary care, as Dr. Granger said, is a really important component.

B (12:32)

You have done tremendous work obviously connecting all the way back to the community health needs assessment. What it lifts it up, how you connect that to a project building in the approach that brings community health workers into the fold and then obviously bringing patients and family members into the fold with you. We could not wish you more luck in the work that you're doing and again couldn't think of a better story to tell. Any closing thoughts before we say goodbye?

D (12:56)

I think thanks for your support and for the dissemination of efforts like this and the impact it has on our community. Thank you.

B (13:03)

Couldn't say it better myself. Thank you both so much.

A (13:07)

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