Success Story: Forming Trusting Relationships with High-Risk Patients

Zufall Health, Dover, New Jersey (2015)

In previous rounds of the Hypertension Control Challenge, Million Hearts® established a benchmark of 70% hypertension control for applicants’ adult populations. This 2015 success story reflects the earlier benchmark.

The Challenge

In 1990, Robert Zufall, MD, and his wife, Kathryn, founded a free clinic to provide medical treatment to northwest New Jersey’s working poor, uninsured, and underserved populations. Today, Zufall Health has nine locations in northwest New Jersey.

Among Zufall Health’s 30,000 patients, 92% are at least 200% below the poverty level and 49% are uninsured. Three in four patients are Latino/Hispanic, and half of these patients are non-native English speakers. Some patients have low literacy levels even in their native language.

When a patient population faces so many challenges, Zufall Health has to go the extra mile to help patients control their blood pressure.

What They Did

Controlling hypertension begins by forming trusting relationships with patients, conveying to them the seriousness of hypertension, and giving them the means to control their blood pressure. When patients experience Zufall clinicians putting so much emphasis on blood pressure control, they embrace the importance of it.

Dr. Rina Ramirez from Zufall Health

“Our providers have really embraced the guidelines and the importance of controlling high blood pressure.”
—Rina Ramirez, MD, chief medical officer, Zufall Health

Formed relationships and built trust

Zufall’s medical van visits soup kitchens during the day to serve homeless individuals and encourage them to receive medical services.

One homeless patient visited the medical van with an initial blood pressure reading of 210/140 mmHg. Over the next 9 months, the clinician worked with the patient and encouraged regular follow-up visits to the center, waived the copays, reinforced and simplified the medication regimen, and assisted the patient in making lifestyle changes. Ultimately, the patient stopped drinking alcohol and cut back on smoking. The patient’s latest blood pressure reading was 137/82 mmHg.

The van also visits migrant farmworkers’ housing in the evenings to accommodate their schedules. When workers need to visit the clinic or get medication, an outreach worker drives them to the clinic.

Zufall clinical pharmacist Elif Özdener meets one-on-one with high-risk patients and those who are having difficulty controlling their blood pressure. She emphasizes the seriousness of high blood pressure and the importance of medications and lifestyle modifications to control it.

“The most important thing is establishing trust,” Dr. Özdener said. “They may feel embarrassed that they can’t afford the medication, but if we have their trust, they can say, ‘I can’t afford this.’”

Zufall Health helps patients obtain affordable medications with the federal 340B Drug Pricing Program and by prescribing from a list of affordable medicines. Zufall Health can also provide free medications to a limited number of patients who cannot afford them.

Took steps for success

The steps that Zufall takes to improve patients’ blood pressure include:

  • Training medical assistants in proper pressure-taking techniques, including having patients settle in before taking blood pressure and retaking it later if the reading is high. Medical assistants perform blood pressure competency testing at least once a year.
  • Reviewing blood pressure guidelines with staff during clinical staff meetings and quarterly grand rounds.
  • Monitoring for hypertensive effects from other medications the patient is taking, such as drugs for pain, and adjusting the regimen accordingly.
  • Teaching patients the skills to manage their own health. Zufall offers wellness programs, including healthy cooking and nutrition, yoga, and adult and children’s exercise classes.
  • Discussing hypertension with patients and giving positive reinforcement when they take steps to reduce their blood pressure.
  • Celebrating small successes or, if a patient does not have a success to celebrate, encouraging them to continue trying.
  • Working as a team. Clinicians communicate with patients and pass along important information or success strategies to other health care team members.
  • Tracking the blood pressure control rate of health care teams and disseminating it among them, harnessing friendly competition to improve control.
  • Using patient navigators to help patients obtain health insurance and other services.
  • Publishing a monthly newsletter to inform and motivate patients to make healthy choices. An announcement about Zufall’s Million Hearts® Champion designation lets patients know that their efforts to control their blood pressure make a difference.

Advice for Others

Zufall’s patient-focused approach to blood pressure control can benefit health care practices of all sizes. Building personal relationships and trust, providing a caring team approach and positive reinforcement, and tracking quality metrics help and support patients who face many challenges controlling their blood pressure, taking their medications, and living a healthier life.

“One of the main tenets of the practice is to give people the information that they need, the skills they need, to manage themselves,” Dr. Ramirez said.

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Page last reviewed: May 5, 2020