Care Team Pre-implementation Perspectives of Collaboration Oriented Application for Controlling High Blood Pressure (COACH)

Context: Hypertension is common and often called the silent killer. Despite ample evidence to support home blood pressure monitoring and timely pharmacologic and non-pharmacologic treatment, many patients experience poor blood pressure control, increasing their risk for stroke, heart attack, and death.

Objective: We explain the application of the Consolidated Framework for Implementation Research (CFIR) to identify the pre-implementation factors for COACH across multiple sites.

Design: Sequential qualitative design using CFIR to guide data collection and analysis; investigators recruited care team members for interviews and observation. CFIR rapid analysis using Dedoose qualitative analysis software. Survey data analyzed using SPSS.

Setting: Nine family or general internal medicine clinics at three academic institutions using Oracle and EPIC EHR platforms.

Population: Primary care teams treating adult patients with hypertension.

Intervention: COACH is a patient-facing and clinician shared decision support tool integrated into the electronic record that captures patient input (e.g., home blood pressure data, goal setting) and is adaptive to users’ preferences, values, and goals.

Outcome Measures: Barriers and facilitators to using COACH across CFIR domains.

Results: We interviewed 72 members of care teams (e.g., clinic managers, coordinators, physicians, nurses, medical assistants, pharmacists) and institutional leaders that will be involved in the pragmatic trial. The primary themes are user-friendly and adaptable design, thoughtful integration into workflows, the importance of supportive policies, and the culture of quality and equitable care. Participants expressed positivity about COACH design, its adaptability, and its advantages in practice. The primary factor for motivating care teams to use COACH was the common culture of care and the potential to improve patient outcomes. Considering EHR alert fatigue and planning for patient and staff education were cited as elements important for engagement and implementation. Institutional support and adaptive reserve varied by site, with some institutions more equipped to seamlessly integrate COACH into existing practices; all sites shared the desire for increased capacity for using home blood pressure as part of hypertension management.

Conclusions: Results from this study can inform pre-implementation planning and promote the successful implementation of COACH and our multi-site pragmatic trial.