CHRONIC CARE: Healthfirst works with community health workers to improve hypertension control in New York’s Asian population

The Challenge: South Asian Americans (immigrants from India, Pakistan, Bangladesh, and surrounding countries) have unique risk factors for hypertension when compared to the general population and face numerous cultural, linguistic, and social barriers to accessing healthcare.

Our Goal: To test the feasibility, adoption, and impact of integrating Community Health Worker-led health coaching with electronic health record (EHR)-based interventions to improve hypertension control among South Asian patients in New York City primary care practices.

The Healthfirst Solution: During the first phase of the project, EHR interventions included generating routine hypertension patient registries within each practice and developing medical alerts and order sets tailored to the South Asian population. A year after the EHR alerts were active, South Asian patients with a blood pressure of over 140/90 were invited to enroll in Community Health Worker-led education and coaching. Community Health Workers conducted health coaching, group sessions on hypertension, and biweekly, individual follow-up calls addressing patient-specific concerns and needs.

Population Health Improvements: 

  • 4.6-point drop in systolic BP over six months, compared to 2.4-point rise in control group
  • 3.7-point drop in diastolic BP over six months, compared to 0.9-point rise in control group
  • 30% improvement in BP control over six months, compared to no change in control group

Takeaway: Project IMPACT builds upon the success of Community Health Worker and Million Hearts® initiatives and proposes a unique integration of provider-based EHR and community-based CHW interventions. The project informs the effectiveness of these interventions in team-based care approaches, thereby helping to develop relevant sustainability strategies for improving hypertension control among targeted racial/ethnic minority populations at small primary care practices.

Additional research source: Protocol for project IMPACT (Improving Million Hearts for Provider and Community Transformation)