Objectives: Hypertension and diabetes mellitus (DM) are the leading causes of cardiovascular, cerebrovascular, and chronic kidney diseases. They affect an estimated 47% and 11% of Americans, respectively. In this study, we assessed whether a dedicated patient navigator embedded within a patient-centered medical home (PCMH) using a structured panel management and patient outreach strategy could improve blood pressure and glycemic control in primary care patients with uncontrolled hypertension and DM.
Methods: We performed a prospective study comparing blood pressure and glycemic control in primary care patients before and after implementation of a patient navigator executing a hypertension and DM-focused panel management plan.
Results: From January 2014 to October 2019, inclusion criteria were met 5164 times, which comprised 1958 unique patients within a PCMH. Multivariate regression analysis reveals a significant decrease in uncontrolled systolic blood pressure (SBP) over time, with an actual decrease of roughly 40% of uncontrolled episodes of SBP becoming controlled by 12 months. Multivariate regression analysis reveals a significant decrease in uncontrolled hemoglobin A1c (HbA1c) over time for each plot (P < 0.0001), with an actual decrease of roughly 30% of uncontrolled episodes of HbA1c becoming controlled by 12 months.
Conclusions: This study demonstrated the benefit of a dedicated patient navigator embedded within a PCMH on improving BP and glycemic control in primary care patients with uncontrolled hypertension and DM. Glycemic control was achieved, with 30% of episodes reaching an HbA1c of <8% and BP control achieved for 40% of episodes with SBP <140 mm Hg at 12 months. There were no differences by the social determinants of race and poverty.