Closing the Gap on Hypertension Management and Outcomes (2026-2027)

Background

Hypertension is the leading modifiable risk factor for cardiovascular disease and contributes to more deaths worldwide than any other chronic health condition. Despite decades of clinical innovation and widespread awareness, blood pressure control rates in the United States remain low and racial disparities remain stark. Only about 48 percent of adults with hypertension achieve adequate control, and Black patients in the U.S. South experience control rates roughly 10 percent lower than their white counterparts.

Black communities face disproportionate barriers to hypertension control, including lack of insurance, inconsistent access to primary care, medication cost burdens, structural racism and fragmented referral systems for addressing social determinants of health. These inequities contribute to earlier onset and more serious complications from uncontrolled hypertension.

Self-monitoring of blood pressure (SMBP), when paired with education, medication management, clinician feedback and integration with health systems, is a proven, guideline-supported strategy that can improve outcomes. However, many systems struggle to implement SMBP equitably. Building on the work of previous teams, this project seeks to evaluate a digitally integrated care model that combines SMBP, telephonic outreach and multidisciplinary follow-up to improve blood pressure control and reduce disparities.

Project Description

This project team will evaluate the impact of a health system and community-integrated hypertension intervention among adults in Durham County. The approach combines:

Free home blood pressure monitors
Structured telephone-based health coaching delivered by trained student navigators
Digital self-monitoring of blood pressure through a secure platform
Screening for health-related social needs (HRSNs)
Referral coordination using the NCCare360 platform
Communication with primary care providers, nurse practitioners, pharmacists, social workers and community health workers

The intervention uses a prospective, single-cohort, pre–post design comparing participants with eligible controls. Participants receive up to three structured telephonic sessions over a three-month period. Calls are guided by evidence-based scripts covering blood pressure education, medication access, behavioral change strategies and goal setting. Navigators document SMBP adoption, HRSNs and medication-related challenges.

The team will analyze blood pressure change over time, adoption of SMBP, medication access, patient–clinician communication and resolution of social needs referrals. Additionally, system integration will be evaluated by quantifying the burden and cost of care processes across the care team.

Anticipated Outputs

Difference-in-differences analysis of blood pressure change at 9 months
Multiple regression analyses to assess the effectiveness of the intervention
Narrative analysis of improvements in patient–clinician communication, SMBP adherence and HRSN referral resolution
Infographics and evidence-based tools to encourage SMBP adoption
Community engagement materials for partner organizations
Conference presentations, journal manuscripts and policy briefs

Student Opportunities

Ideally, this team will include 4 graduate students and approximately 16 undergraduate students. Students with interests in community health, digital health, public policy, health disparities, data analysis, nursing or medicine are encouraged to apply.

Students will gain experience in:

Patient interaction and telephone-based health coaching
Data collection, entry, cleaning and statistical analysis
Digital health implementation and electronic health record workflows
Community outreach and collaboration with local partners
Policy analysis and communication strategies to support SMBP adoption
Preparing manuscripts, posters and community-facing materials

Graduate students will serve as subteam leads and mentors. One graduate student will be selected to serve as project manager.

Timing

Summer 2026 – Spring 2027

Summer 2026 (optional):

IRB amendments, literature review, and focus groups with community partners

Fall 2026:

Data collection across two parallel workstreams (telehealth intervention; policy engagement)

Spring 2027:

Data cleaning and analysis
Preparation of presentations and manuscripts

Crediting

Academic credit available for fall and spring semesters