Utilizing a web-based clinical registry to align community-based, person-centered care with improved health outcomes in hypertension via the Vermont health information exchange

Background: In October 2011, the Vermont Department of Health and the Support and Services at Home (SASH) program began a partnership that linked clinical practice and SASH Community Health Workers to reduce hypertension among SASH participants. SASH utilizes a team model of coordinated health care and social support for elders and persons with disabilities living in affordable housing developments. The system is linked by two key components, Community Health Workers and the online clinical registry into which all SASH data is entered. This registry feeds the Vermont Health Information Exchange and allows for community health data to be viewed directly by hospitals and medical home practices. Methods: The SASH assessment in the registry was revised to include measures for hypertension and reports about the number of SASH participants seeing their primary care providers (PCP). A comprehensive plan was developed to execute and track the self-management of hypertension protocols in the registry. Results: The clinical registry was implemented in May 2012, among 353 SASH participants. Registry reports show 66% of participants received an annual exam from their PCP and 4.2% have received a coordinated intervention between the PCP and the Community Health Worker. 28% of SASH participants self-reported at the initial assessment that they are treated for hypertension by their PCP, but few reported self-monitoring. Since protocol implementation in January 2013, registry data shows that hypertension self-management has increased to 32% of participants. Conclusions: The integrated registry and self-management practices help improve care coordination and hypertension outcome measures.