Culture of Health: Hypertension Transcript

Dr. Nwando Anyaoku
Hello everyone and welcome to culture of health show that zeroes in on healthcare matters that disproportionately affect communities and highlights ways to break down systemic barriers of care, especially for underserved communities. On this podcast, we will talk to healthcare professionals and hear stories that inform and inspire listeners to bravely navigate healthcare with dignity, care and humanity in a quest to achieve health equity.

I'm your host, Dr. Nwando Anyaoku, Chief Health Equity and Clinical Innovation Officer here at Providence. And here with me today, Dr. Sonia Mehra, a primary care physician, a health equity advisor and clinical lead for Pacific Medical Centers in the greater Seattle area. And also Karla Gomez, who's manager for health equity for the South Division. I invited them on the show today to help us understand the healthcare issues around hypertension, high blood pressure and the disparities in underserved population. Why it hits these populations at a higher rate and what we're doing about it. Hello and welcome Dr. Maddox and Carla, it is so great to speak with you today. Can you tell us a little bit about yourself and the work you're doing at Providence? I will start with Karla.

Karla Gomez
Thank you so much, Dr. Nwando. So happy to be here today. And thank you for having me. So, as I said, I'm Karla Gomez. A little bit about myself. I've been at Providence a little over a year now. And I've been a manager for our health equity initiatives, meaning I help oversight, bring guidance, perhaps leadership and partnership with some of our various different departments trying to launch health equity initiatives.

Some of our biggest initiatives here currently, right now, our North Gate, just we're markets here. So we have a partnership that we're building out with them. And we have another project under US called Black Mama's going and right now our biggest project, which we're here today is our hypertension project, which we launched back in 2021. Right after the pandemic, when we saw what from what we saw. And really this year, the focus has been a scaling it in the ambulatory care setting. Previous versions were always in the community setting. So we're kind of integrating what we learned in that community setting and bringing it into the ambulatory setting. So I've been calling that with my PC and colleague, Lisa Wada, and just trying to make sure that we can, you know, reach our goals this year.

So thank you for having me. Oh, look at my background really quickly. I am a SoCal native, I am a first gen I am Spanish, I'm bilingual. I always like to say I am my own case study of like why I got into this work. I'm very passionate of the work I do. I did my undergraduate in in Davis, I have a Chicano Studies, social policy. I have my masters in from USC working in the tiller care systems and public administration. So that's some of my background, and really what guided me and pretty much put me here today of the work I do. So thank you for having me.

Dr. Nwando Anyaoku
Fantastic. Thank you. Dr. Maddox?

Dr. Sonja Maddox
Hello, and thank you for having me again. I am a primary care doctor, a family medicine doctor who has been working for Pacific Medical Center's for almost 19 years now. I work out of the Renton clinic, and I am also the health equity clinical lead. And so at PAC Med, what that means is that after 2020, like a lot of organizations, when we started looking more deeply at our quality data.

And before 2020, no one really had looked at how well we were taking care of our patients when you separated them based on race and ethnicity. And so when we started looking lo and behold, we found that not all of our all of our patients were being taken care of as well. And so that's when we started forming our health equity team. So we have health equity supervisor, I work closely with a co partner, Diana in our administrative part of Pac med. And we have a team of community health workers who reach out to our patients. And so one of the very first health initiatives that we started working on was hypertension.

When we looked at our data, initially, we could see that our black patients of all of the groups our black patients were not taken care of as well compared to our other patients. This past year, we've expanded our focus groups to essentially bipoc patients because all of the groups were not being taken care of as well. And so as as we've gotten better at learning how to do this work, we've been able to incorporate more groups as our focus, but I was just looking at our data, you know, before we started in 2021 63% of our black patients did not have their blood pressure controlled and at the end of May of this year, we're at 68%. So by percent improvement is great. but it's still low like we want, we want to keep working on that. And so I am happy that we're here today talking about hypertension.

Dr. Nwando Anyaoku
I love it. I just want to pause and recognize these amazing professionals who have put your heart and everything into doing this work and the work you do everyday for our patients. I just want to appreciate you.

For our audience. Let's level set a little bit. Let's tell our audience who are not all clinical, we have a lot of people who are non medical listening to us today. And let's set for them. What is hypertension? Why are we worried about it? What are some of the issues that could arise? What is hypotension?

Dr. Sonja Maddox
I can take that one, how I explain it to patients, it's elevated blood pressure that's in their blood vessels. And when I've talked to them about it, they'll ask me, Well, what does the top number versus the bottom number mean? And what I explained is the top number is like if I were to stick a tire gauge in you, what's your pressure when the heart is pumping? When it's contracting? And then the bottom numbers, what is when it's relaxed? And so they're like, oh, okay, that makes sense.

And what I talked about is, you know, most of the time when people have high blood pressure, they may not notice, because they feel fine. That's why high blood pressure has been called the silent killer for many years, you don't really notice until it's been going on for a long, long time. And, you know, complications that we worry about, it increases your risk of heart attack, stroke and kidney disease. And the goal is, is to have people that are we're recognizing their high blood pressure before it leads to those later.

Dr. Nwando Anyaoku
Fantastic. When you were your team, you talked about the work you've been doing in the community around this. What are you finding people ask about this? Different communities understand that concerns and what we're working on? What have we learned from that work?

Karla Gomez
Yeah, absolutely. So when we're working in the community setting, what we saw is that there's a disconnect between understanding sometimes the health care system for a lot of our community members, a lot of people, it's not that they don't want to go into the clinic, it's sometimes they don't have like access transportation, they don't know how to like navigate their insurance, so often they avoid it.

So really, when we were working in the community setting, that was our focus, we were focused on connecting with them, meeting them where they're at, which we're, it's really focused on what we call in our setting right now is the social determinants of health screening them trying to see where they're at meeting them where they're at, and kind of hearing from them of how to connect them to the health care setting.

And really highlighting a lot of these disparities and why they're important and why something like hypertension is so critical to take care of yourself at as young age or early on as you're diagnosed because of the underlying conditions and what we saw during COVID. So that's really the highlight of what the work was we were doing prior in our previous past versions, before we went more into the ambulatory care setting.

Dr. Nwando Anyaoku
Fantastic. Thank you. So you know, both of you talked about how important it is to understand this concern. And we, you know, this podcast really talks about the fact that some populations to your point caller experience the care that we intend to deliver, as you mentioned earlier that dramatically differently, we show up as healthcare providers, caregivers, physicians, and all we show up every day without a game intending to care for everyone the same way.

And yet, when you broke down the data, as described earlier, we saw that there was opportunity there for some of our populations, the care that we were intending to deliver was not landing in the same way, and we're not getting the same outcome. So what are some of the key factors that contribute to those disparities? Why was it different?

Dr. Sonja Maddox
So, at the onset, when we started doing this work, two of my colleagues, Dr. Park and Dr. Ludwig, they were actually able to look back at data and do a review of our patients in a managed care population they looked at so one of the questions or one of the things that comes up for people is like, are the patients taking their medicines? Are they doing what we're asking them to do?

So, the assumption is that our patients are not doing what we've asked them to do that they're just not following through. So, they went and we were able to look back and they could see that actually, the medication fill rates were exactly the same whether or not patients were white or black. So, it's not that patients are not doing what we're asking them to do.

When they were able to look back, we did also find that more often than not, if the blood pressure was elevated, it may not been addressed by the caregiver, or it was like, Oh, it's just I'm having a bad day. It was situational and there wasn't necessarily a Have a plan for the patient to return. And so that's part of what we're seeing. I think, also it's there's when people go the doctor, everybody has a lot of expectations.

And I think it is hard to take care of everything all at one visit and healthcare is expensive. You know, it's confusing. Do you trust the doctor that you go see? Are they taking care of me how they should be? You know, we talked about a lot of historical differences in care why people are fearful to go to the doctor. But those things happen in present day as well. And so people bring with them all of that fear. There is a lot of medical traumas. When people come the doctor, I see it a lot. They are scared when they come and are not sure what to expect or who to trust.

Dr. Nwando Anyaoku
Powerful words. You mentioned earlier color, you have something you want to add to that?

Karla Gomez
No, just it right this spot, it's like that the year. And I hear that sometimes it's just like they're filling what is what lab coat or white lab coat syndrome, where there's just this fear of being honest during these doctor's appointments, and being truthful, because they feel that they're gonna get in trouble. And we see that a lot in the Latin X community is just like not being honest, in their assessments sometimes and not being truthful, because they're scared and based on previous trauma, or from what they've heard from others.

Dr. Nwando Anyaoku
You had mentioned what you found in terms of access to health care system, right, so that some people didn't know how to access or navigate the insurance. How does that impact the control and management of hypertension in underserved communities?

Karla Gomez
Yeah, not knowing where to go, it really matters because they don't know where to start. A lot of them don't know that they're assigned a primary care physician, especially people who are in communities who might be first generation, we see that a lot. They wait until the last minute sometimes until something's critical to go to the doctor versus really having that knowledge of why it's important to be aware of preventative health being a top of that.

So just having like not knowing how to navigate, that just kind of is a barrier, because instead of when something is addressed, like something comes up, they end up just kind of reframing and putting into the last minute we hear a lot. And then until something critical finally comes up, it's when they finally go. Sometimes there is a lack of late first language accessibility, is they speak another language they don't want to call in, they might not understand that nowadays, there's a lot of like phone trees where they get lost. And instead of just going and trying to call in, they might just put it off until something critical happens.

So here and so can we actually use our community health worker model as well, we've been piloting that and really scaling it to kind of help support that with the access to care and being that guide to be able to navigate the health system. So as we're connecting patients to like the pharmacy program we use here, the community health worker will be in partnership with the pharmacists that meet to the patient for medication management, and answer any questions they may have, such as like connecting them to transportation, any foods, resources in the community.

If they want to know how to get to the behavioral health department, they can provide that support. So really just that comfort and being someone from that community in that ambulatory care setting.

Dr. Nwando Anyaoku
I love it. I've just to think about what you both have described is all the different ways that patients are challenged, right? So they've got to get through access, understanding the doorway is getting through the phone trees, getting to see a physician regularly, right. And then when they get there, are they anxious? Do they feel safe? Do they feel seen their trust concerns? Do we make sure that they come back? Right?

So there are all these barriers that you're describing that patients experience? And these are even more challenging for underrepresented communities? Because, you know, some of these are difficult. So just to continue on the line that you've both started to mention, Dr. Maddox, let's talk about what are some things that we're doing some strategies that we're putting in place to start to address this hypertension control, especially for the underserved population.

Dr. Sonja Maddox
So at this, you know, this is what I'm really proud of why I keep coming back to do this work is because by having community health workers, we've been able to show that we're able to make changes and so what they do is they reach out to our patients we look at whose blood pressure is controlled and who's not. And reach out and try to connect with people and help try to bring them back and see what things do they need to help be more successful to help reach their health care goals to help them feel like they're not lost in this big system and that their doctor does care about their health and we have interventions are planned, we gave out blood pressure cuffs, we can connect them with the clinical pharmacists, send them to nutrition, check back with their primary care doctor. So they're by having these extra interventions, we know that when we keep an eye on blood pressures, we're able to reduce some of the health gaps.

Dr. Nwando Anyaoku
I love that. And so the whole team is involved. You've got the doctor, you've got the nurses, the clinical pharmacist and community health worker, really a team approach to addressing these disparities. And I wonder how this bringing the 360 degree solution right having everybody on board to solve for these disparities? Does it actually make it more personalized? I think Karla talked about it being the cabinet guy, can you speak a little bit about how that I think people feel cared for?

Karla Gomez
So like when I start talking about the reasons why just like I explained at the beginning, you know, why are we doing this and and people recognizing like, we know we as healthcare providers recognize that there is a problem. And the way we were doing it before was not working. And so we have eyes on this now. And we want to include you in the process and know that you are cared for. And so I when I share this with people they're interested in and are looking for the extra assistance, the extra eyes to help so that they can be as healthy as they can be.

Dr. Nwando Anyaoku
I love it. Carla, where do you get your community health workers from, we try to identify someone close to that clinic.

Karla Gomez
So I want to make sure it's someone from that demographic, typically what the clinic sold, the individual can relate. So we are very strategic. And who we hire, we want to make sure it's someone that understands the community they are working with, are open to learning about the community they're working with, because that will allow the patient to build that connection. And then for us, our community health workers continue to still work in the community at 20%, to be able to be that individual in the community that they see. But also they're going to see at the clinic, when they meet with for they go in for their appointment. So we're still making sure that they're still attached to the community setting and still in the clinic. So that's what we've been working on.

Dr. Nwando Anyaoku
So we've talked about the community health worker being an advocate for the patient. And you've talked about the clinical pharmacists, right. So we've got what else are we doing? Have we looked at other treatments or interventions that are not necessarily medical? Right? are we addressing diet and, and lifestyle? And how are we going about that?

Dr. Sonja Maddox
We know that healthy, healthier eating and regular exercise, we know those things help bring blood pressure down. And if I had unlimited resources, that would be something I would provide. But unfortunately, we don't we have limited resources to do all of this. And at some point, I want that to be part of what we're able to offer for patients.

Now what are social workers and community health workers are looking at like they look at the patient's insurance can do they have like a benefit at the gym or something? But it's hard to do all of the things. And so ideally, yes, that would be that is that as a goal, but we it's not come to fruition for us at least yet.

Karla Gomez
I could speak a little bit at least in here in California, where we've been building, specifically in Southern California is we've been working very closely with our disease management department as kind of like an advisory committee, where we have our identify leaders from pharmacy, nutrition and education. And really together we meet to build system and different REIT bringing our expertise to build out a program that we can meet the patient in where they're at and provide them different resources.

So when we reach out, we provide them an educational program right away within that engagement in that engagement, initial engagement, but we also bring them into the clinic. So we work collaboratively and try to figure out what can we build together. And in addition, we also have our health equity champions, which are PCP leaders across our different ministries, who really advocate at the clinic and answer any questions for our other medical doctors that we have. They're very involved in the work that we're doing.

So we've found that that's very successful and bringing awareness to the program and really being able to have multiple lens in the work by having different leaders in put in the work and trying to bring it together for that patient based on where they're at and meeting based on their needs.

Dr. Nwando Anyaoku
I love it. We're having these conversations always feels my heart because there's so much energy and passion happening across our enterprise that People don't, you know, we might not even know about. And I wanted to, step back and focus on the PCP part, because I think one of the things you mentioned earlier Dr. Maddox is the review that showed that the patient's fill rate was not any different.

But I'm thinking that the fill rate reflects, the percentage, `how much proof they were prescribed, compared to how much they failed? But if they didn't show up, right? Or if you didn't set up a follow up appointment, if there wasn't, then there's going to be a gap, right, that might not reflect? Have we looked at that? And how are we making sure that we make sure patients have follow up appointments so that they're scheduled to see their PCP? How is a problem?

Dr. Sonja Maddox
For us, the community health workers kind of helping close that gap? And so when we review blood pressures at the, you know, end of the month, like our people, you know, where are we have, and then they'll go back and look at patients that they've been talking with and see who needs to go back. But, you know, a lot of times, patients will want to go back, but they can't get an appointment for a couple months. And I mean, that tends to happen regularly, it's hard, there are fewer and fewer primary care Doc's unfortunately, and so it's hard to get in to see your doctor.

So that is also a barrier that we find. And one other thing I did want to mention kind of in preparation for this talk, I was looking up by like the CDC, what they said in terms of what things contribute to high blood pressure, and they describe it as lifestyle choices. And that really bugged me. And I wanted to put that out there. And I it bugs me, because there is an assumption that when people's blood pressure or whatever their medical problem is, is that they are choosing to eat poorly, or choosing not to exercise, when really there are a lot of barriers, like people are working multiple jobs to pay for their health insurance, people don't have time to cook a nutritious meal after they've been working, you know, 10 hours a day, you still got to take care of your kids get adequate sleep.

So I had I had that irked me, and I just wanted to share that it is not just a choice. People want to be healthy. And I think yes, we can guide them. But when it's come at, like you have this problem, because you're not doing what you're supposed to do, when in actuality, we know that chronic stress and if you are a black or brown person that is much more likely that leads to hypertension, weathering, chronic elevation of cortisol levels like it is not just because there's something in us that causes us to have high blood pressure, the things that happened to us cause this problem and so I just want to make sure I said that for everybody to hear.

Dr. Nwando Anyaoku
I hear you. Thank you.

Karla Gomez
The dire would they like that just added? Yeah, definitely like these individuals, if they don't want to have hypertension, but unlike the communities, like there's food deserts, often black and brown communities, we see that their food desert, a food desert is where there is no nutritional food near you. There's more fast food, we tend to see accessibility we tend to see like sometimes there's lack of sleep multiple jobs, they want to be able to go to the doctor but it's inaccessible, it's hard.

They're not typically available during business hours. I used to work in a working in Monterey County for the at with rural California. And what we saw when the rates were higher for like the the growing season, we tended to see less people in the clinic because that's when they were working. That's where they think of you know, I don't know if you guys are familiar with Maslow, Maslow's hierarchy of needs, it's if you don't address your foundation, you can worry about your health. So that's the foundation you need to be able to address your what is your food, your breathing water, shelter, clothing and sleep in order to be able to address your health next. So it definitely can speak to you know, kudos, and yeah, it definitely agree with that.

Dr. Nwando Anyaoku
I love it. And I love that this is what we do in this work is to recognize that each individual comes to us with a different starting point. They have different challenges. And so in order for us to give them their best care, which is what we're committed to do, we need to understand that and take into account the factors in their life. So partnerships, like you described, Karla with your with the grocery store, where you can actually make it possible for them to have access to healthy food or being able to refer to a food bank or just understanding what their context is. So it's so very important. I mean, we can have this conversation all day long. But I wanted to ask, Is there are there any issues that we haven't raised that you want to make sure I brought in? Dr. Maddox has shared one and you can share another if you have one. But Karla, is there anything you want to bring into this space that we haven't talked about?

Karla Gomez
I think we addressed the foundation It's just like, I'm really excited where we're going with healthcare, I think for we're seeing this community health worker model really being highlighted in the news. So I'm excited to be a part of it, because I think we're thinking very creatively and innovatively of where we're going with healthcare and a 360 approach. So I'm just Yes, we've learned from the past, but that doesn't mean we have to continue in the same fashion. We're learning from the past, or be more open minded. And that just really fills me and drives me in this work. So that's my closing statement.

Dr. Nwando Anyaoku
Thank you. Thank you, Dr. Maddox.

Dr. Sonja Maddox
No, I just really appreciate being here and hearing about all the work that we're all trying to do, it refills the pot, so it makes me motivated to keep doing it. And I'm glad that there are others excited to do the work as well.

Dr. Nwando Anyaoku
And talking to you and talking to all of our leaders just filled my cup, and that for my, for my patients and everyone. So thank you so much for joining us today on culture of health. We look forward to continuing the important conversations on health equity issues with more experts from Providence family in future episodes, make sure to listen to all our shows and lit live radio on the future of health radio, or your favorite podcast platform.

And follow us on social media. We can be found on x and Facebook at Providence and on Instagram under Providence Health Systems. To learn more about our mission programs and services, go to providence.org. And please remember the information provided during this program is for educational purposes only. You should always consult your healthcare provider if you have any questions regarding a medical condition or treatment. Thank you so much for listening.

Thank you. Thank you