Practice Facilitation Blueprint: Clinical Integration of Self-Measured Blood Pressure (SMBP)(DRAFT)
Version for PCORI-Funded CHARMED Study by UCSF and UC Davis
Key Tasks
Task 1. Confirm Leadership Buy-In to SMBP QI
Task 2. Form an SMBP Improvement Project Team
​​Task 3. Review "Best Practices" & Models for Ideas
Task 4. Set Improvement Goals and Define Population
Task 5. Get to know resources in EHR and related IT systems for SMBP
Task 6. Generate list of PoF patients
Task 7. Set Treatment Goal/s for SMBP
Task 8. Confirm how to fund devices & what validated BP will be used
Task 9. Determine where patients will get the device & be onboarded to its use
Task 10. Decide how patients will document SMBP and share with clinic
Task 11. Develop or improve training program for patients
Task 12. Determine how care team will act on SMBP data that is submitted
Task 13. Map & Test Key SMBP Workflows Using PDSA Cycles & Refine
Task 14. Create Job Aids and Train PCPs & Staff
Task 15. Monitor implementation with Last 10 Patient Chart Audits
Task 16. Incorporate SMBP into the Practice QI Plan
Task 17. Add SMBP to JDs, evaluations, onboarding training, standing agendas
Task 18. Document & Share the Clinic's Lessons Learned Learned with Peer Practices and other PFs
Background
Purpose of this Guide
This guide is for Practice Facilitators, Primary Care Providers (PCPs), office managers, medical assistants (MAs), and quality improvement (QI) teams.
It’s a step-by-step blueprint designed to help you improve how your practice identifies and closes care gaps — whether in preventive care, chronic disease management, or behavioral health.
You’ll find:
  • A quick start guide if you only have a few minutes at a time to work on this
  • list of essential tasks for improving care gap closure processes in a PCP
  • Worksheets for each task you can use to help practices reflect on and plan improvements
  • Real-world case examples from “exemplars” in care gap closure
  • “PEARLS” — pro tips from the field
  • A reusable structure you can use to address different care gap closure processes or HEDIS-like metrics
Contents of this Guide
The SMBP improvement process begins with three essential prework steps:
  • engaging practice leadership,
  • forming a dedicated CGC project team, and
  • conducting a brief current state assessment of the clinic’s current gap closure processes
Following this prework, the practice team completes a structured sequence of 12 tasks that guide them through the full cycle of quality improvement—from defining a SMBP goal to identify populations of focus and determining how to source BP devices to mapping workflows, to testing changes, training staff, evaluating results, and fully integrating the new process into the clinic’s quality infrastructure.
Together, the prework and tasks provide a practical roadmap for a PF, office manager or PCP QI team for building sustainable, team-owned workflows that close care gaps efficiently and equitably.
Ways to Use this Guide
This guide is designed to be practical and flexible—whether you’re a Practice Facilitator supporting multiple clinics or a clinic leader (such as an office manager or lead clinician) guiding your own team.
While you can follow the tasks in order, it is intended to be a flexible guide, where you can select the tasks that aling best with the needs of the practice you are supporting.
Ways to Use This Guide:
  • Facilitator-Led: Use the guide as a roadmap to structure your coaching sessions with a practice, focusing on one task at a time.
  • Practice-Led (No PF On-Site): Clinic leaders can walk their team through the guide, using it to lead short, focused improvement huddles or meetings.
  • Peer Coaching: Share the guide with a trusted peer or colleague at another clinic and work through tasks together.
  • Support from Health Plan or IPA: Ask your health plan or IPA if they can provide a facilitator or quality coach to help you implement the guide.
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About Self-Measured Blood Pressure (SMBP)
Self-measured blood pressure (SMBP) is an evidence-based strategy in which patients monitor their blood pressure (BP) outside the clinical setting—typically at home—with the support of their care team. SMBP has been shown to significantly improve hypertension (HTN) control. A meta-analysis of remote monitoring interventions demonstrated meaningful reductions in systolic and diastolic BP (effect sizes of 1.1 and 0.98, respectively). The approach is particularly promising because it enables patients to engage actively in their care and allows clinicians to make more accurate treatment decisions by relying on out-of-office readings, which are often more reflective of true BP levels than those taken in the clinic.
Despite its promise, SMBP has not been implemented with broad or consistent access across patient populations. Utilization rates are lower among individuals from historically underserved communities, those with limited English proficiency, and patients seen in safety-net health systems. Implementation challenges—such as device access, data integration into the EHR, and inconsistent workflows—have limited uptake in routine care.
What Good Looks Like in SMBP in Primary Care
An effective Self-Measured Blood Pressure (SMBP) program, as outlined by the CDC and Million Hearts®, incorporates accurate home monitoring, proper patient technique, clinical integration, and supportive infrastructure. Patients should use validated devices and follow best practices for measuring blood pressure—such as sitting quietly for five minutes, ensuring proper positioning, and taking multiple readings at consistent times of day.
Clinical teams must provide ongoing support through education, interpretation of readings, and feedback to guide lifestyle changes or medication adjustments. Integration of SMBP data into the electronic health record and workflows allows for timely action and treatment titration. Addressing structural barriers—like access to devices and insurance coverage—and leveraging community partnerships are also essential to broadening reach and impact. When implemented with fidelity, SMBP improves blood pressure control, enhances engagement, and contributes to better cardiovascular outcomes.
Citations:
Centers for Disease Control and Prevention. “Self-Measured Blood Pressure Monitoring at Home.” https://www.cdc.gov/bloodpressure/measure.htm
Million Hearts®. “Self-Measured Blood Pressure Monitoring.” https://millionhearts.hhs.gov/tools-protocols/tools/smbp.html
Centers for Disease Control and Prevention. “Self-Measured Blood Pressure Monitoring: Action Steps for Public Health Practitioners.” https://stacks.cdc.gov/view/cdc/164208
Some Resources
  • CHARMED Resource Box: Go here to access a repository of resources for all aspects of SMBP curated by the CHARMED team.
  • Care Simple Materials: Go here to access training on CareSimple and here for a CareSimple Job Aid
  • NYCs Toolkit for PFs on SMBP: Go here for an NYC Toolkit on SMBP for Practice Facilitators with a range of handouts and guidance
Start-Up Activities
Orientation Training for Clinic QI Champion
As the Practice Facilitator (PF), your first step is to orient the site’s Champion to the project using the slide deck if they have not already completed the orientation, or if they are a newly assigned champion.
During the orientation, emphasize their role in supporting practice-level QI on SMBP—not in recruiting patients for the study. Reinforce that their focus is to help the team define goals, support workflow redesign, and sustain momentum around SMBP implementation.
Use the "Blue Bucket/Red Bucket" slide to help the Champion distinguish between the research study which is being handled by a central research office at UCSF and each county system (blue) and the practice’s own QI work on SMBP (red), and reframe it as needed to ensure clarity.
Champion orientation slide show
Click here
Champion FAQ
Training on CareSimple & Testing CareSimple Credentials
Ensure the Champion and key staff complete CareSimple training, either live or recorded, covering patient enrollment, data access, and communication tools. After training, help them log in and test their credentials by accessing a sample dashboard or sending a test message. Quickly address any access or technical issues with the CareSimple support team to prevent delays.
Conduct a Current State Assessment (CSA) of SMBP
Use the worksheet below to help the Clinic Champion and SMBP QI team complete an assessment of the current state of SMBP at the clinic. This information will help the Champion and SMBP QI team determine the improvement goals they will pursue over the next 12-24 weeks.
A CSA should include:
  • a review of current and past SMBP programs,
  • current SMBP workflows, and
  • a "last 10 audit" of patients receiving SMBP support or with elevated BP (see instruction in appendix)
If no SMBP processes are currently in place, the "last 10 audit" can focus on patients with elevated BPs (> 140/90 or the standard the clinic uses) to look at current workflows for supporting them, and opportunities for implementing SBMP.
Use the results to refine goals set under task 3 if needed.
Current State Assessment Template
Check Prior work in participating systems

Prior SMBP Work at Ventura

Ventura. The Ventura team, funded through HRSA, has prior experience implementing SMBP and has already developed workflows to support patient identification, device distribution, and data collection. Their hands-on work provides a strong foundation for refining and scaling SMBP efforts, offering practical insights into what works in real-world clinic settings. This existing infrastructure positions Ventura well for continued improvement and alignment with current SMBP quality goals. POTENTIAL EXEMPLAR HRSA funded SMBP w/ workflows for Cerner: Go here Outreach script to patients on SMBP: Go here My Chart SMBP entry review and response protocol. Go here

Prior SMBP Work at Contra Costa

West County's BP Phone Outreach West County Health Center implemented a targeted blood pressure (BP) phone outreach initiative focused on African American patients and individuals with diabetes, two populations at higher risk for uncontrolled hypertension and its complications. Using tailored scripts, staff made proactive calls on behalf of primary care providers to encourage patients to come in for an urgent BP recheck. The outreach emphasized the importance of BP control in preventing heart attacks and strokes, especially in communities disproportionately affected by these conditions. Each script referenced the patient’s most recent BP reading, explained its significance, and offered to schedule a follow-up visit with the patient’s doctor. This personalized, clinician-connected approach helped reinforce the importance of BP management and facilitated timely care. In January, Contra Costa initiated additional workflows for SMBP led by Dr. Richey at West Count. (Zach Lewis: Champion) West County's BP Phone Outreach protocol. Go here Contra Costa's Phone Outreach for Elevated BP. Go here

Prior Work on SMBP at San Francisco Health Network

The San Francisco Health Network (SFHN) established a comprehensive, standardized protocol to support Registered Nurses (RNs) in managing uncomplicated hypertension in primary care settings. This protocol empowers RNs to titrate medications, monitor patient progress, and provide structured education based on evidence-based guidelines. The target population includes adult patients (18+) with diagnosed hypertension, and care follows clearly defined clinical criteria and exclusion guidelines. Nurses are authorized to perform key functions such as validating home blood pressure monitors, educating patients on lifestyle modifications, collecting self-monitored BP readings, and adjusting medications based on protocol parameters. The protocol also emphasizes close collaboration with providers, requiring RN consultation under specific circumstances like high-risk conditions, abnormal labs, or symptomatic hypertension. With clearly delineated workflows, documentation standards, and follow-up procedures, this approach strengthens nurse-led hypertension management while maintaining clinical oversight and ensuring patient safety. SF Primary Care Nurse Standard Procedures and Protocols (inc SMBP). Go here Go here for HTN treatment protocols, medication details and treatment algorithms developed by San Francisco HN

KEY TASKS
Task 1. Confirm Leadership Buy-In to SMBP QI
Before the Clinic SMBP QI Champion launches SMBP QI work at the clinic, work with them to engage clinic leadership to confirm leadership buy-in for SMBP QI and alignment of this work with clinic priorities. Encourage them to meet with their clinic director or QI or population health team lead to discuss their interest in facilitated QI work on SMBP for CHARMED.
Task 2. Form an SMBP Improvement Project Team
Next work with the Clinic Champion to assemble a cross-disciplinary team for SMBP QI for the clinic. Their role will be to plan and test SMBP improvements.
Include representatives from key roles such as nursing, medical providers, medical assistants, front desk staff, quality improvement, and IT or EHR support. Complete the worksheet below with the Clinic Champion to determine who should serve on this team.
​​Task 3. Review "Best Practices" & Models for Ideas
A. Work with the Champion and team to review and select clinical support model for SMBP that fits with their practice culture, resources and patient needs.
Explore existing evidence-based clinical support models for SMBP and determine the most feasible type of support for your work environment. Consider:
  • Staff
  • HIT
  • Budget
B. Review exemplar programs.
Do a quick review of these "exemplar" models with the Champion and their team for ideas for their own site:
Successful Self-Measured Blood Pressure (SMBP) programs in primary care settings share key design features: structured patient engagement, integration with EHR systems, staff workflows to act on data, and a culture of continuous improvement. Below are three leading programs demonstrating effective SMBP implementation, followed by best practices for Epic and Cerner EHR systems.
Click here for an article on "lessons learned" from 5 FHQCs on SMBP
Exemplar 1. Ochsner Health (Louisiana)
Ochsner’s Connected Health program uses Bluetooth-enabled devices and an integrated app to transmit patient readings to the EHR. A nurse care team is alerted when patients’ readings fall outside target ranges, prompting timely follow-up. This model streamlines communication, ensures rapid clinical response, and has been linked to significantly improved blood pressure control.
  • Key Outcomes:
  • Over 71% of SMBP participants achieved BP control
  • Decreased hypertension-related ED visits
  • Workflow Elements:
  • Wireless BP devices sync with a mobile app (Connected Health)
  • Real-time data uploads to EHR
  • Automated algorithms flag concerning trends
  • Nurse care team receives alerts and contacts patients
  • PCPs adjust medications based on SMBP trends
  • Patient education integrated into onboarding
  • Reference:
Exemplar 2. Reliant Medical Group (Massachusetts)
Reliant incorporates SMBP into hypertension care using a device connector platform that enables seamless Bluetooth integration into the EHR. Clinical teams access structured data views, monitor trends, and respond via health coaches and clinician follow-up.
  • Key Outcomes:
  • Accelerated hypertension diagnosis and titration
  • Improved adherence to care plans
  • Workflow Elements:
  • SMBP device syncs automatically with a connector platform
  • Readings flow directly into the EHR
  • Critical readings are flagged and reviewed
  • PCPs supported by RN and MA follow-up
  • Health coaches provide motivational counseling
  • SMBP discussions integrated into care plans
  • Reference:
Exemplar 3. Health Federation of Philadelphia (Pennsylvania)
This network of FQHCs uses grant-funded SMBP programs to expand access to BP monitors and train patients to self-report. While data is often manually reviewed and entered, consistent SMBP integration during visits and follow-up has improved engagement and care outcomes.
  • Key Outcomes:
  • Increased patient engagement Stronger alignment of SMBP with visit-based care
  • Workflow Elements:
  • Wireless BP cuffs distributed to patients
  • Data submitted via apps, logs, or phone calls
  • MA or RN reviews readings and enters into EHR flowsheet
  • SMBP results discussed during follow-up visits
  • CHWs and health educators support training and reminders
  • Reference:
Exemplar 4. Ventura via HRSA (PENDING)

The Ventura team, funded through HRSA, has prior experience implementing SMBP and has already developed workflows to support patient identification, device distribution, and data collection. Their hands-on work provides a strong foundation for refining and scaling SMBP efforts, offering practical insights into what works in real-world clinic settings. This existing infrastructure positions Ventura well for continued improvement and alignment with current SMBP quality goals.

The Ventura team, funded through HRSA, has prior experience implementing SMBP and has already developed workflows to support patient identification, device distribution, and data collection. Their hands-on work provides a strong foundation for refining and scaling SMBP efforts, offering practical insights into what works in real-world clinic settings. This existing infrastructure positions Ventura well for continued improvement and alignment with current SMBP quality goals.

C. Review possible SMBP models
If the practice already has an SMBP program in place, work with them to define the model and assess its alignment with best evidence and best practices for that approach.
WORKSHEET
RESOURCES
MH_SMBP_Clinicians.pdf (For support models and overall implementation methods)
Task 4. Set Improvement Goals and Define Population
A. Select Population of Focus (PoF).
Identify which patients will be prioritized for SMBP support - the Population of Focus for SMBP. This could include:
  • adults with uncontrolled hypertension,
  • those newly diagnosed
  • patients with significant barriers to in-clinic monitoring, or
  • specific equity-focused groups.
Review the Chart below from the National Association of Community Health Centers for ideas and rationales: https://www.nachc.org/wp-content/uploads/2023/02/NACHC-Health-Care-Delivery-SMBP-Implementation-Guide-08222018.pdf?utm_source=chatgpt.com
B.
Clarifying the target population helps focus outreach, streamline workflows, and ensure that SMBP efforts are directed where they can have the most impact. Encourage the team to start with a manageable group and expand over time as capacity grows.
B. Select SMBP improvement goals.
Next work with the Champion and the SMBP team to define their clinic’s specific improvement goals for SMBP. Use insights from the CSA to guide the discussion, helping the team select one or two measurable goals that reflect both clinic priorities and key gaps—such as improving patient engagement with SMBP or integrating SMBP data more consistently into clinical workflows.
Use the worksheets below to help the Champion and QI team define their improvement goals and PoF for SMBP
Population of Focus Worksheet
SMBP Goal Setting Worksheet
Task 5. Get to know resources in EHR and related IT systems for SMBP

EPIC & SBMP

Integrating SMBP into the electronic health record is critical for care team engagement and clinical decision-making. Below are resources on EPIC. EPIC Functionalities that can support SMBP Epic’s system includes robust tools to support remote monitoring and provider response. These include: MyChart SMBP Entry: Patients enter readings via the portal Flowsheets: Capture and graph readings in structured fields Care Companion: Assign SMBP tasks and reminders to patients SmartSets/SmartTexts: Streamline orders and documentation Best Practice Alerts (BPAs): Trigger action for abnormal readings Dashboards: Monitor SMBP data across patient panels HIT Optimization Resources: Epic Share: https://www.epicshare.org/ Overview Video for My Chart for patients: https://youtu.be/gpqIB7ovoic Sign-up for MyChart Video for Patients: https://www.youtube.com/watch?v=XD588k6Pf_w My Chart on Computer Video Overview for Patients: https://youtu.be/Omg_H9RdWEQ How to enter BP readings in My Chart (2020): https://www.youtube.com/watch?v=lKzxSdgzhXg Workflows & Resources from Participating Systems: Contra Costa Workflows for SMBP using EPIC (Pending) SF HP experience using Care Companion PENDING. — [email protected] Return to TOC

CERNER & SMBP

Cerner resources used in SMBP workflows include: HealtheLife Patient Portal: Direct SMBP entry from patients PowerChart Touch: Mobile documentation and review Flowsheets & Templates: For SMBP-specific tracking Smart Reports: SMBP dashboards for QI and panel management Order Sets & Note Templates: Consistent workflows for follow-up Vendor Guidance: Custom configuration and training tools available Home dot phrase: Go here for CHARMED resource on this Patient automated outreach on SMBP: Go here for CHARMED resource on this HIT Optimization Resources: Cerner provider training (general) https://www.rsfh.com/providertraining/ Ventura Workflows for SMBP using Cerner developed during HRSA Grant (Pending) - Rachel Stern MD [email protected] and Marivel Guevara [email protected]

Task 6. Generate list of PoF patients
Task 7. Set Treatment Goal/s for SMBP
A. Define treatment goals for SMBP
Next help the Champion engage clinical leadership to define standardized treatment goals for the SMBP program.
Help them engage leadership in discussions about Implementing standardized hypertension treatment protocols and related order sets and referral templates to enable the full care team to titrate medications, ideally using preferred clinical guidelines to define entry criteria, treatment goals, preferred medications, and management of side effects.
  • Engage clinical leadership and providers to agree on a BP control threshold based on current guidelines or payer metrics (e.g., <140/90 mmHg for HEDIS, or <130/80 mmHg for more intensive control).
  • Facilitate discussion with the care team to ensure the selected goal aligns with the clinic’s patient population, capacity, and clinical priorities.
  • Ensure the treatment goal is clearly communicated to all staff involved in SMBP—from front desk to providers—so that follow-up actions and messaging are consistent.
  • Incorporate the goal into workflows and tools, including EHR templates, training materials, and patient education, to support reliable documentation and tracking.
  • Use the BP targets as benchmarks for measuring the clinic’s SMBP performance over time and identifying areas for improvement.
This shared treatment target becomes the clinical anchor for all SMBP activities—helping align efforts, guide decisions, and evaluate impact.
B. Document to include in SOP
Work with the champion to document information developed so far about SMBP to put in the Standard Operations Manual (SOP). You can use the worksheets you have completed so far as the basis for the SOP.
Worksheet: Establish a Treatment Goal for SMBP
Task 8. Confirm how to fund devices & what validated BP will be used
A. Determine how to fund devices.
Blood-pressure cuffs can cost up to $75—a price tag some patients who have been economically or socially marginalized can’t afford. Work with the Champion and team to determine how patients will obtain SBMP devices.
Options include:
  • Paid for by health plan/insurer
  • Purchased by health center (for patient to keep)
  • Clinic-Owned Loaner Devices (Returned After Use)
  • Purchased by patient
  • Already owned by patient
  • Purchased by supporting organization (for patient to keep)
Information on Reimbursement
FIRST, Check here for coverage types and options by state: https://map.ama-assn.org/resources/smbp-coverage-insights-medicaid
SECOND, identify the SME in the practice or healthcare system who is familiar with reimbursement for SMBP and reach out.
THIRD, review the following information on state of reimbursement currently:
MediCal (YES): In California, MediCal patients with hypertension related ICD 10 codes are eligible to receive a SMBP device. Note: California does not provide reimbursement for related services for SMBP such as education yet.
MediCare (NO MOSTLY): Medicare generally does not cover the cost of home blood pressure monitors except for patients with end-stage renal disease and for a 24- hour period once a year for patients who have difficulty providing an accurate BP measure in clinic because of white coat hypertension or other reasons. HOWEVER, MediCare does reimburse for certain SMBP-related clinical services:
  • CPT Code 99473: Patient education and training on the use of a validated home blood pressure monitor, including device calibration.medicarefaq.com
BUT some MediCare Advantage Plans (YES POSSIBLY) plans may provide reimbursement for SMBP devices as well as related services. Check with the Medicare advantage plans for your patients.
FOURTH, check with specific plan for the health system and their processes and policies re: SMBP.
Complete the worksheet below to do this.
Resources:
Go here for an overview of reimbursement policies in California for SMPB devices for MediCal and MediCare Patients

RESOURCE FOR VENTURA COUNTY: Dr. Rachel Stern is knowledgeable about health plans paying for SMBP devices - specifically Gold Coast - and also where patients can obtain them - She indicates DME stores are the place to go. She will provide an SME training on the learning collaborative and will also provide a tip sheet. She notes that paying for devices will vary by County. [email protected]

RESOURCE FOR CONTRA COSTA COUNTY: Dr. Sarah Richey at Martinez in Contra Costa.
TBD Promising practice: Device procurement PENDING (Wosen at Miller is developing a survey of patients that already have devices as a "start-up".) [email protected]
B. Select a validated device to use
Work with the Champion and team to select a validated, upper-arm device to use.
a. Decide on level of device connectivity
  • Standard Upper Arm Cuff (Manual Entry Required)
  • Bluetooth-Enabled Devices (Transmit to Third-Party App or Platform)
  • Cellular-Enabled Devices (Transmit Automatically Without Wi-Fi or App)
  • Devices Integrated with EHR (via Remote Patient Monitoring Platforms)
  • Random Patient-Owned Devices (unknown types and validation status)
b. Address any PoF accessibility needs such as:
  • language
  • literacy
  • e-literacy
  • low vision
  • cuff size (Standard/Large Cuffs (fits arm sizes 8.75” – 16.5”), Extra-Large Cuffs (fits arm sizes 15.75” – 21.25”)
  • affordability
c. Select one or more validated devices:
To be covered by MediCal benefits the device must be "validated." This means that a blood pressure device has undergone rigorous, independent clinical testing and meets internationally accepted accuracy standards (such as AAMI/ISO or BHS protocols).
Go here to find a list of "validated" BP devices that meet the above criteria: https://www.validatebp.org/
WORKSHEET
RESOURCES
See the list of validated BP Devices: www.validatebp.org
Task 9. Determine where patients will get the device & be onboarded to its use
A. Determine where patients will get device
Work with the Champion and team on how devices will be distributed to patients. This may be dictated by the patient's health plan or it may be possible to negotiate distribution methods with the payer, for example having the devices sent to the clinic rather than the pharmacy.
Common distribution methods include:
  • At clinic
  • Mailed to the patient
  • At pharmacy
  • At DME store
  • Delivered by clinic staff or street medicine team
Promising practices:

VENTURA Promising Practice: Pick-up at Partner Pharmacies and DME providers
Dr. Rachel Stern. Has a list of DME stores where patients can pick-up devices. TBD. [email protected]
Academic Family Medicine (Ventura) At Ventura’s Academic Family Medicine Clinic, Jackie called 15 pharmacies to see if they would "dispense" SMBP devices. Of the 15, 7 agreed to stock and dispense the devices with an RX. These 7 were all family owned small pharmacies that also provided DME. None of the larger more commercial pharmacies were willing to stock and dispense the devices.
For more information contact Jackie Wong at [email protected]

CONTRA COSTA Promising Practice: Clinic as Pharmacy w/ Single Visit Enrollment Model
Martinez Health Center (Contra Costa) Contra Costa's Martinez clinic is exploring use of a "single visit enrollment model" where the patients are prescribed and given the SMBP device at the visit and receive training from the SMBP educator on use of the device and logging BP values on My Chart on the same day.
For more information contact Shirley Xu at [email protected])

"Physician practices can tell patients how to order these devices—what to put on the prescription form and that the code for ordering them is benign hypertension. They can also coach patients on how to identify their durable medical equipment provider, which is sometimes hard to figure out.
Insurance policies vary among patients, said Dr. Manary. And prior authorization is sometimes required, depending on the patient’s Medicaid coverage. Physicians can reference this comprehensive guide on prescribing SMBP for Michigan Medicaid patients (PDF) to get more details.
One way to avoid prior authorization is to choose the health plan’s preferred durable medical equipment provider, she suggested."
Task 10. Decide how patients will document SMBP and share with clinic
A. Determine how patients will document & submit BP values
Once device options are determined, agree on how patients will document their BP results, how often, and when and how they will provide these to their PCP or clinic. These method or methods should align with the BP devices, clinic workflows, EHR integration capabilities, and patient preferences and needs. Make sure the method follows the Health Insurance Portability and Accountability Act (HIPAA) regulations
Common methods include:
  • Handwritten logs
  • Secure patient portal entry
  • Patient app entry
  • Automated bluetooth transmission to EHR or 3rd party platform
  • Secure e-mail between patients and clinicians
  • Phone call reports to clinician
WORKSHEET
Documentation Methods Worksheet
B. Work with the Champion and clinic team to design a standardized, patient-centered process for acquiring and documenting SMBP readings for clinical use.
This process should define how patients will be instructed to submit readings, the expected frequency of submission (e.g., twice daily for 7 days), and the methods the clinic will support for data collection.
Consider the clinic’s workflow capacity, EHR capabilities, and patient preferences when selecting options. Multiple methods may be needed to accommodate diverse populations. Common options include:
  • EHR Integration via Remote Monitoring Platforms (e.g., CareSimple or other Bluetooth-enabled devices with direct data upload)
  • Patient Portal Submissions where patients enter readings manually into a secure platform
  • Secure Text or Email Messaging with protocols for who monitors and inputs the data
  • Paper Logs, which patients bring to appointments or submit via fax/photo
  • Phone Call Check-ins, where staff record readings directly into the EHR
  • Kiosk Entry or Staff Entry at Clinic Visits, especially for patients without digital access
Select and document the approach(es) that best fit the clinic’s population and resources, ensuring all staff are trained to support the process consistently.
Include a process for accessing data from CareSimple for the 100 patients from the clinic that will be enrolled in the Patient Arm of the Charmed Study. For this:
Worksheet: Data Collection
Go here for CHARMED resources on SMBP data collection and entry
Task 11. Develop or improve training program for patients
Begin by deciding how patients will be onboarded and educated about taking and submitting readings, how often they should submit them, instructions for how to obtain accurate readings, the value of SMBP, tips and tricks to remember to measure, and instructions for how to send to clinic, and how to engage in healthy self-management of blood pressure.
Models for delivering patient education include:
  • One-on-one in-person training during office visits or nurse-led SMBP education sessions
  • Group education classes, either in person or via Zoom
  • Written instructions or how-to packets with diagrams and FAQs
  • Short instructional videos, shared via text, patient portal, or clinic website
  • Live telehealth walk-throughs at the time of device distribution
  • Printed SMBP logs for manual tracking, or
  • Digital solutions like CareSimple, mobile apps, or EHR-integrated tools for remote data submission
Patient access needs
  • Literacy level and languages
Modules
  • Using device
  • Taking accurate measure
  • Uploading
  • Managing your health
Resources for patient education sessions include:
  • Materials at your system's shared site
  • Materials in the CHARMED box
  • Materials at Million Hearts website
  • Materials at AHA
  • Materials at CDC
  • Materials at Target BP
Use the worksheet below to develop a preliminary design or set of improvements for the clinic's SMBP patient education component.
WORKSHEET
RESOURCES
Task 12. Determine how care team will act on SMBP data that is submitted
A. Decide how staff and PCPs will support patients and act on SMBP data
  • Outreach calls to support SMBP enrollment and ongoing participation
  • Technical support for patients using home BP monitors or remote platforms
  • Patient education on interpreting readings and when to seek care
  • Follow-up workflows for elevated or uncontrolled BP readings
  • In-clinic or telehealth reassessment following medication changes or uncontrolled BP
  • Documentation procedures for capturing SMBP data in the EHR and triggering clinical review
B. Define treatment protocols, order sets and referral templates to support full team participation.
As the PF, support the Champion in defining or adopting clear protocols for each of these processes. Include specific roles, responsibilities, and workflows for clinical follow-up and patient engagement. Having structured, clinic-approved protocols helps standardize care, reduce delays, and ensure SMBP data leads to meaningful action. Examples of key actions to include in these protocols are:
  • Outreach calls to support SMBP enrollment and ongoing participation
  • Technical support for patients using home BP monitors or remote platforms
  • Patient education on interpreting readings and when to seek care
  • Follow-up workflows for elevated or uncontrolled BP readings
  • In-clinic or telehealth reassessment following medication changes or uncontrolled BP
  • Documentation procedures for capturing SMBP data in the EHR and triggering clinical review
Work with the Champion to adapt these protocols to fit the clinic’s capacity and existing workflows, ensuring all team members understand when and how to act on SMBP data.
Go here for the Million Hearts SMBP response protocol algorithm
Go here for resources on acting on SMBP data from CHARMED
Task 13. Map & Test Key SMBP Workflows Using PDSA Cycles & Refine
Use Plan-Do-Study-Act (PDSA) cycles to test the new or enhanced workflows. PDSAs are “small tests” of the new or redesigned process. It is an iterative process where you test your new workflows with one patient, or with one care team, or for one day, study what worked and didn’t work, refine the process based on that information, test again, until the process is ready to fully implement.
Use PCP and staff and patient feedback and modified Last 10 chart audits to study the workflows. Do as many small tests as you need to do until you are ready to scale and spread to the entire practice.
For a brief review of process mapping to share with a practice go here:
WORKSHEET
You can use this module to provide a quick training to the practice on PDSA cycles: https://www.ahrq.gov/downloads/ncepcr/pf-modules/model-pdsa/story.html
WORKSHEET
Task 14. Create Job Aids and Train PCPs & Staff
A. Job aids
Develop simple, role-specific job aids to support each step of the SMBP workflow—such as referring patients, educating them on device use, documenting readings, and following up on out-of-range results. Use plain language, visuals, and clinic-specific instructions. Train staff using brief walkthroughs, role-based sessions, or team huddles, and embed job aids into daily workflows for easy access.
Be sure to include job aids for accessing and incorporating CareSimple data. You can incorporate information from this CareSimple job aid here.
Worksheet: Job Aid Template
B. Train. Collaborate with the Champion and clinic leadership to develop a comprehensive training plan that prepares all clinicians and staff to implement the SMBP workflow consistently and confidently. Effective training should be tailored to different roles and learning styles, using a mix of methods to reinforce understanding and promote adoption. The goal is to ensure everyone—from front desk staff to providers—knows their role in the SMBP process, how to communicate with patients about it, and how to document and act on SMBP data accurately. Training should be practical, team-based, and tied to the real-world workflow the practice has developed. Use the worksheet below to design the training.
Recommended Training Approaches:
  • All-staff and provider meetings to introduce the SMBP model and emphasize clinic-wide alignment
  • Role-specific small group trainings for Medical Assistants, nurses, and providers to focus on task-level responsibilities
  • 1:1 coaching or shadowing to support learning-by-doing, especially during early implementation
  • Booster sessions during daily or weekly huddles to reinforce key points and address emerging questions
  • On-demand digital modules or recorded sessions for flexible, self-paced learning
  • Platform-specific training (e.g., CareSimple training for CHARMED clinics) to ensure staff can navigate technology tools confidently
WORKSHEET
RESOURCES
Resources for training MAs and RNs can be found here
CHARMED RESOURCES
Task 15. Monitor implementation with Last 10 Patient Chart Audits
Once training is complete, support the Champion in leading the team through the implementation phase. This includes setting a clear go-live date, identifying a short trial period to test workflows, and encouraging staff to use new processes with real patients. Make it easy for staff to ask questions and surface challenges by holding regular check-ins or using existing huddles.
During the first few weeks, use last 10 patient chart audits to monitor how the workflow is functioning and address issues promptly. Calculate and track missed opportunity rates to pinpoint where breakdowns are occurring and to track improvements.
Encourage feedback, celebrate early successes, and adjust the workflow as needed based on real-time experience. Thoughtful implementation ensures that training translates into reliable practice and that SMBP becomes a sustainable part of the clinic’s routine.
Once the workflows are functioning consistently, scale back audits to monthly, and eventually to quarterly once SMBP is well established. This ongoing audit process helps sustain fidelity to the workflows, supports continuous improvement, and keeps the team engaged in SMBP quality and outcomes.
Task 16. Incorporate SMBP into the Practice QI Plan
Work with the Champion and team and QI leadership to formally add SMBP implementation to the practice’s Quality Improvement (QI) plan. Including SMBP in the QI plan ensures it is treated as a clinic-wide priority with clear accountability and alignment with existing improvement goals. Incorporating these metrics into the QI plan allows the team to monitor progress over time, guide workflow refinements, and support data-driven improvement conversations during regular QI meetings.
Collaboratively identify and document specific metrics to track progress and performance. Some ideas include:
  • Number or percentage of eligible patients enrolled in SMBP
  • Missed opportunity rates for referrals and patient onboarding
  • Percentage of SMBP participants submitting readings as scheduled
  • Percentage of SMBP readings documented in the EHR and reviewed by clinician
The practice can use Last 10 audits as one way to gather these data and calculate these metrics
Other metrics to consider include:
  • Change in blood pressure control rates among SMBP participants compared to non-participants
  • Overall performance on HEDIS-Like metrics
Task 17. Add SMBP to JDs, evaluations, onboarding training, standing agendas
To sustain SMBP as part of routine care, work with clinic leadership to embed SMBP responsibilities into core clinic operations. Update relevant job descriptions to include SMBP-related tasks—such as patient education, data documentation, and follow-up—for roles like MAs, nurses, and care coordinators.
Incorporate SMBP performance into staff evaluations where appropriate to reinforce accountability. Ensure new staff are trained on SMBP workflows during onboarding. Finally, make SMBP a standing item on clinical team meeting agendas to support regular updates, troubleshoot barriers, and share progress. Integrating SMBP into the clinic’s infrastructure helps ensure long-term consistency and success.
Task 18. Document & Share the Clinic's Lessons Learned Learned with Peer Practices and other PFs
Encourage the Champion and team to share their tips and tricks, PEARLS and lessons learned with others in the CHARMED study and in their social network. Sharing successes (and lessons learned) supports cross-site learning, fosters collaboration, and builds momentum for SMBP improvement across the network.
Help the Champion to document the learnings in a simple format—such as a short write-up, slide, or infographic—and share them with peer clinics through the learning community.
Worksheet: PEARLS and Lessons Learned Vignette Documentation
Appendix
Documenting PF Work for SMBP QI for CHARMED
1) ENCOUNTER NOTE: PFs should complete an encounter form immediately following each visit here
Or on LA Net's website at https://www.lanetpbrn.net/pfcharmed
2) FORMS IN THIS BLUEPRINT: Complete for each task completed by a site and save in the google file here:
CHARMED Resources for PFs working with Study Sites
PFs can access resources gathered by the CHARMED team and associated practices during start-up and design phases of the study HERE.
Additional Learning for PFs supporting SMBP Implementation
For comprehensive implementation strategies and additional resources:
  • NACHC SMBP Implementation Guide: Provides detailed steps for integrating SMBP into clinical practice, addressing community engagement, reimbursement, and health information technology challenges.nachc.org
  • Million Hearts SMBP Resources: Offers tools and protocols to establish SMBP monitoring programs, including action steps for clinicians and public health practitioners.millionhearts.hhs.gov
Conducting a "Last 10 Patient" Audit of SBMP or HTN Workflows with PoF
A. Map the existing high-level SMBP workflow or elevated HTN workflow
Start by having the team map out the current SMBP workflow as it truly exists—not as they wish it functioned. This should be a collaborative, step-by-step process involving the individuals who perform each task, based on their actual actions rather than assumptions or memory. Use the High-Level Workflows for SMBP worksheet to capture this.
WORKSHEET
B. Conduct a "Last 10" Audit of the last 10 patients seen who are in the SMBP program or who have elevated HTN
Once the workflow is mapped, guide the team in assessing its effectiveness through a “last 10 patients” chart audit to identify where breakdowns or inconsistencies occur. If it is too overwhelming or difficult to look at 10, have the Champion start simple - with a single patient.
How to Do a Last 10 Patient Chart Audit
A “Last 10” Patient Chart Audit is a simple, hands-on way for practices to understand how their current workflow is (or isn’t) working, or for them to take a deeper look at the PoF they plan to engage. This "quick look" audit looks at what actually happened with recent patients, rather than relying only on reports or memory.
10 is not a magic number, you can start by looking at a single patient, or 5, or 20. Pick a number that is do-able, and provides enough information to give you and the Champion insight on the practice's existing processes.
Steps in a Last 10 Patient Chart Audit
1) Pull the records for the last 10 patients
Seen in the practice who were eligible for that service/care process.
2) Review each record
To see whether the p w r f S a wh the indicated steps of the SMBP workflow were followed.
3) Document barriers & facilitators
Document reasons for the step not occurring (barriers) as well as reasons it did (facilitators). You and the Champion can use this information in improvement work.
4) Calculate the “missed opportunity” or MO rate for the step/s of the SMBP process being assessed
Take the total number of patient charts reviewed and divide this into the total number of patients who did NOT receive the indicated care in the workflow. Multiple by 100 and this will give you the Missed Opportunity "rate" or in this case "percentage." For example, if the Champion reviews the charts of the last 10 patients in for a visit who were eligible for referral to the SMBP program, and finds only 4 were referred, this would be a 60% missed opportunity percent.
PEARL: MOs are a way to track improvement: The Champion and their team can use this MO percentage to monitor the impact of changes they make to their workflows. Effective changes will lower the MO percent or rates.
5) Analyze the "root cause" of missed opportunities
As a next step, identify the most frequent reasons for missed opportunities (MOs) and analyze their root cause. Teach the Champion and team the simple "5 Whys" process and use this to examine the reasons for the MOs, and then use this information to set improvement goals in the next step of this Blueprint process, and guide selection of changes to workflows to reduce MO rates.
Use the Last 10 Audit worksheet below to collect and organize the data.
For a quick training for the Champion on Last 10 Audits use: https://www.ahrq.gov/downloads/ncepcr/pf-modules/chart-audit/story.html
WORKSHEET
As a second step, for clinics that have existing SMBP workflows work with the Root Cause Analysis of the Results of the Last 10 audit to identify areas to improve.
C. Use the "5 Whys" to explore Root Causes for Missed Opportunities to fix (or successes to spread)
After completing the Last 10 chart audit, work with the Champion and team to conduct a root cause analysis of the most common reasons for "missed opportunities" in the workflow.
The 5 Whys is a simple but powerful tool for identifying the root cause of a problem. It works by asking “Why?” five times—or as many times as needed—to dig beneath the surface of a missed opportunity and uncover the underlying reasons it occurred.
Use this information to improve and re-design the existing workflow.
For a brief training on the “5 whys” and other tools for conducting root cause analysis, view this module: https://www.ahrq.gov/downloads/ncepcr/pf-modules/5-whys/story.html
It’s especially effective when used as a team activity and should be applied to both problems and successes to identify what’s working well and where improvements are needed.
SMBP Device Reimbursement Policies in California
In California—as in the rest of the U.S.—Self-Measured Blood Pressure (SMBP) services can be billed using specific CPT® and HCPCS codes. These are used to document and get reimbursed for activities such as training patients, collecting and analyzing SMBP data, and follow-up care.
California-Specific Billing Guidance
In California:
  • Medi-Cal FFS (Fee-For-Service) follows national CMS guidance, including use of 99473/99474.
  • Managed Care Plans (e.g., LA Care, Gold Coast, Health Net) may have their own submission portals and workflows. Some allow for device distribution via clinic inventory, while others require pharmacy-based fulfillment.
It's crucial to check with the specific health plan or IPA for:
  • Prior authorization needs
  • Device distribution process (clinic vs. pharmacy)
  • Use of CPT codes vs internal billing workflows
Key SMBP CPT & HCPCS Codes
CPT® Codes (Professional Services) Code Description
Check device validation here: www.validatebp.org
Important: These codes can be billed by physicians and certain qualified healthcare professionals (e.g., nurse practitioners, PAs).
HCPCS Codes (Equipment/Supplies) Code Description
Check device validation here: www.validatebp.org
Note: Medicaid Managed Care Plans like Gold Coast Health Plan may directly supply devices to patients or reimburse pharmacies. Providers may need to use internal prescription systems or supply request processes rather than submitting this HCPCS code themselves.
Reimbursement Tips
  • 99473 is generally paid only once per lifetime per provider per patient.
  • 99474 requires systolic and diastolic averages based on at least 2 readings per day over 2 days.
  • Documentation must include training, review of readings, communication of treatment plan.
Resources:
Understanding these policies ensures that your clinic can:
  • Select SMBP devices that are reimbursable under Medi-Cal Rx (A4670/A4663), reducing patient out-of-pocket costs
  • Correctly code for provider services using CPT 99473 and 99474
  • Prepare for any prior authorization requirements, avoiding patient-level delays
Together, these resources empower your PF and Champion to confidently navigate device selection, billing, and workflows for successful SMBP implementation in California.
Environmental Scan and Context Resources for the (3) participating systems
San Francisco Health Network (SFHN)
SFHN has integrated Community Health Workers (CHWs) into its hypertension health equity initiatives. The Hypertension Health Equity Project launched in 2015 involved CHWs as part of a comprehensive effort to improve blood pressure control among African American patients.
Source: CDC Preventing Chronic Disease (2024)
PDF: https://stacks.cdc.gov/view/cdc/136535/cdc_136535_DS1.pdf
Contra Costa Health Services (CCHS)
CCHS employs CHWs through programs like CommunityConnect, which provides telephonic case management, health education, and resource navigation. These programs focus on clients with chronic conditions and social needs, leveraging CHWs as core team members.
Source: California Health Care Foundation (CHCF)
PDF: https://www.chcf.org/wp-content/uploads/2021/02/RoleCHWsCommunityConnect.pdf
Ventura County Health Care Agency (VCHCA)
VCHCA provides services to a diverse population through mobile health units and emphasizes culturally and linguistically appropriate services. This includes distributing bilingual materials and offering care through mobile teams in rural communities.
Source: Ventura County Health Care Agency – Health Equity and Cultural & Linguistic Services
Website: https://hca.venturacounty.gov/heac/cultural-linguistic/
About QIP
The Quality Improvement Program (QIP) is a California-specific program administered by the California Department of Health Care Services (DHCS). It is not a federal CMS measure, although it often aligns with national standards like those from NCQA's HEDIS, CMS Core Measures, or other recognized clinical quality metrics. For detailed information go here: https://www.dds.ca.gov/rc/vendor-provider/quality-incentive-program/
Clarifying the Relationship
QIP = California State Program
  • Designed by DHCS for Medi-Cal managed care plans.
  • Aims to improve care quality and outcomes in California’s Medicaid program.
  • Includes incentives based on performance against California-specific benchmarks.
  • QIP measurement sets often include clinical measures from HEDIS, but the incentive structure, benchmarks, and scoring are determined by DHCS, not CMS.
QIP ≠ CMS Quality Payment Program
  • CMS operates federal programs like:
  • QPP (Quality Payment Program) for Medicare providers.
  • Medicaid Adult Core Set (which states like CA may adopt). o MIPS, ACO, and other payment models under federal Medicare authority.
  • These may include similar measures (e.g., Controlling High Blood Pressure) but operate under federal policy and oversight.
QIP Measure Calculation for Hypertension (CBP) This training guide introduces how to calculate and understand the QIP performance measure for blood pressure control among adults with hypertension. It is designed to help Practice Facilitators (PFs), quality improvement staff, and clinicians grasp the components of the measure, how performance is assessed, and how it ties into California’s QIP benchmarks and incentives.
  1. Measure Overview
  1. The Controlling High Blood Pressure (CBP) measure is part of the California Quality Improvement Program (QIP) for Medi-Cal managed care plans. It is based on NCQA’s HEDIS specifications and focuses on improving blood pressure control to reduce the risk of cardiovascular events.
  1. Measure Name: Controlling High Blood Pressure (CBP)
  1. Program: California DHCS Quality Improvement Program (QIP)
  1. Target Population: Medi-Cal members aged 18–85 with a diagnosis of hypertension
  1. How the Measure is Calculated
  1. Understanding how this measure is calculated is essential for identifying opportunities for quality improvement. The calculation involves identifying eligible patients (denominator), those with controlled BP readings (numerator), and ensuring exclusions are applied correctly.
  1. Denominator (Eligible Population)
  1. Adults aged 18–85 as of December 31 of the measurement year
  1. Diagnosed with essential hypertension (ICD-10 code I10)
  1. Must have had at least one outpatient visit with a hypertension diagnosis between January 1 and June 30 of the measurement year
  1. Exclusions:
  1. Patients with end-stage renal disease (ESRD), pregnancy, hospice, or palliative care
  1. Numerator (Performance)
  1. Patients in the denominator whose most recent blood pressure reading during the measurement year was:
  1. Systolic <140 mm Hg
  1. Diastolic <90 mm Hg
  1. QIP Scoring Methodology (DHCS
  1. The QIP program rewards Medi-Cal managed care plans for performance and improvement. Plans receive points for each measure based on how well they meet benchmarks or improve upon past performance. These points convert into incentive payments.
  1. Scoring Rules
  1. Full points: Earned if performance is at or above the High Performance Level (HPL)
  1. Partial points: Given for year-over-year improvement from a prior baseline
  1. Zero points: Assigned if performance is below the Minimum Performance Level (MPL) with no improvement
4. Benchmarks for CBP (MY2023)
  • Each year, DHCS publishes benchmarks—called the MPL (Minimum Performance Level) and HPL (High Performance Level)—for each measure. These define the thresholds for earning incentive points and allow comparison across plans. Benchmark Values – Measurement Year 2023
5. Summary Table of Calculation Steps
Below is a quick-reference table summarizing the core steps to calculate the CBP measure and interpret performance. PFs can use this to guide clinics in identifying gaps and improvement strategies.
The CHARMED Study
To address these gaps, the Patient Centered Outcomes Research Institute (PCORI) has funded investigators at the University of California San Francisco (UCSF) and the University of California Davis (UC Davis) to conduct the Championing Hypertension Remote Monitoring for Fairness and Dissemination (CHARMED) study.
CHARMED is a multi-site, factorial randomized controlled trial of SMBP being conducted in 25 primary care clinics across three large safety-net health systems in California: the San Francisco Health Network (SFHN), Ventura County Medical System (VCMS), and Contra Costa Health Services (CCHS). The study focuses on English- and Spanish-speaking patients with uncontrolled hypertension and is notable for its dual emphasis on effectiveness and implementation science.
CHARMED includes two primary intervention components:
  • A Patient-Facing Remote Monitoring Intervention
    Patients are randomized to receive:
  • Lower-Intensity Support: A cellular-enabled BP device (CareSimple), text message reminders, and instructions for regular SMBP.
  • Higher-Intensity Support: All lower-intensity components plus tailored educational and motivational text messages to support HTN management and behavior change.

  • Clinic-Facing Implementation Strategy
    Clinics are randomized to receive:
  • Baseline Training Only: A virtual session on evidence-based SMBP practices, access to a clinician resource repository, and initial workflow design support.
  • Baseline Training + Ongoing Practice Facilitation: Monthly support sessions to refine and implement clinic-level SMBP workflows, promote EHR integration, define team roles, and build capacity for sustainability.
Study Goals and Outcomes
  1. The CHARMED study includes two key components:
  1. Patient Study Arm (CareSimple)
  1. Up to 100 patients per clinic are enrolled in the CHARMED SMBP study and receive a Bluetooth-enabled CareSimple BP monitor. These patients are followed for specific clinical and engagement outcomes.
  1. Practice Facilitation Arm (12 high-intensity clinics)
  1. Clinics randomized to this arm receive structured, monthly PF support for approximately one year.
  1. PFs will help these clinics integrate SMBP into routine care workflows using any tools or models they have or choose to adopt—not limited to CareSimple.
  1. The PF work supports implementation of SMBP workflows for both study and non-study patients.
  1. Patient Study Outcomes (CareSimple Users Only)
  • These outcomes apply only to patients enrolled in the study using the CareSimple BP device:
  • In-clinic systolic blood pressure (EHR)
  • Home systolic blood pressure (CareSimple platform)
  • BP control rates (<140/90 mmHg and <130/80 mmHg) (CareSimple and EHR)
  • Medication intensification (change in number of antihypertensive drug classes) (EHR)
  • SMBP data submission (adoption metric) (CareSimple usage logs)
  • Medication adherence (Krousel-Wood scale) (patient survey)
  • Patient experience (PACIC-SMBP survey) (patient survey)
  • Reach: proportion of eligible patients enrolled in the CareSimple study
Quote from protocol regarding reach:
“Reach: Proportion of eligible patients enrolled in the CHARMED study SMBP program using CareSimple.” (Protocol, p. 18)
Clarification: Reach is a metric tied only to study patient enrollment in the CareSimple arm. It is not a goal/influenced by PF work with clinics or by SMBP adoption outside of the study.
3. Practice Facilitation Outcomes of Interest
  • The goal of the PF arm is to support clinics in improving their infrastructure and capacity to implement and sustain SMBP workflows in daily care. PFs may support study and non-study patients using any SMBP tool or method. Outcomes of interest include:
  • Clinic workflow adoption for SMBP (measured via facilitator logs and interviews)
  • Clarification and integration of team roles in SMBP (MAs, RNs, pharmacists, CHWs)
  • Fidelity to SMBP workflows (consistency of execution, EHR documentation)
  • Integration of SMBP into daily clinic routines
  • Sustainability planning for SMBP workflows post-study
  • Improvements in BP control rates driven by improved SMBP practices
4. Scope of PF Support
  • Practice facilitators provide structured coaching tailored to each clinic’s context, capacity, and tools. PFs are expected to:
  • Support new SMBP implementation, including in clinics that have no SMBP protocols in place aside from CareSimple use with study patients.
  • Assist with adoption of any SMBP models, such as Omron devices, paper logs, MyChart entries, or verbal reports—depending on clinic preference and resources.
  • Guide development of sustainable workflows, including standardized follow-up, escalation protocols, and structured documentation practices.
  • Facilitate team-based care planning by clarifying roles for MAs, RNs, and others.
  • Provide regular performance feedback, coaching, and improvement strategy support.
Key quote from protocol on PF role and flexibility:
“The practice facilitation intervention is designed to help clinics integrate SMBP into routine care delivery using whatever tools and workflows best fit their clinic context.” (Protocol, p. 11)
“Facilitators will tailor coaching based on each clinic’s capacity, infrastructure, and preferred SMBP tools.” (Protocol, p. 22)
Clarification: While CareSimple is used for standardized patient outcome measurement, PF support is not limited to CareSimple use and extends to broader SMBP infrastructure, including start-up in clinics with no existing protocols.
5. What PF Work Does Not Include
  • To ensure focused support, PFs are not expected to:
  • Provide coaching for general hypertension care that is unrelated to SMBP
  • Deliver direct patient services such as lifestyle coaching or medication counseling
  • Support unrelated QI initiatives (e.g., cholesterol, diabetes) unless linked to SMBP
  • Expand reach or enrollment in the CareSimple arm (this is not a PF responsibility)
6. Summary for PF Use
  • PFs should focus on:
  • Developing, refining, and sustaining SMBP workflows
  • Supporting clinic use of SMBP with both study and non-study patients
  • Assisting in the selection and adoption of tools or devices suited to the clinic
  • Coaching team-based SMBP management
  • Aligning SMBP workflows with clinic goals, including QIP measures
  • PFs should not focus on:
  • General HTN management workflows without SMBP
  • CareSimple recruitment, tech troubleshooting, or post-study patient device use
  • Broad QI coaching unrelated to SMBP
Key Driver Model
A Key Driver Model is a visual framework that outlines the essential system components—or "drivers"—that must be in place to achieve a specific improvement goal, such as better blood pressure control through SMBP. These drivers are typically evidence-based and include areas like team-based care, use of data for improvement, patient self-management support, and reliable delivery of evidence-based care.
Practice facilitation programs use a Key Driver Model to guide their coaching by helping clinics identify which drivers they already have in place, where gaps exist, and which change ideas or workflow adaptations can strengthen each area. The model provides a shared roadmap for clinics and PFs, ensuring that facilitation efforts are focused, strategic, and aligned with broader quality improvement goals.
The CHARMED key driver model for SMBP improvement is built around a set of primary drivers—core elements that must be in place to achieve the study’s aims of (1) improving performance on PRIME/HEDIS-like metrics, (2) improving BP control among the focus population, and (3) improving overall health outcomes. Each driver is linked to specific change ideas and interventions that PFs can support clinics in implementing.
Primary Drivers and Associated Change Strategies:
  1. Knowledgeable, Prepared Care Teams
    PFs help assess and build the care team's knowledge of SMBP through team training, dissemination of educational materials, and integration of SMBP into regular staff meetings and workflows.
  1. Standardized Treatment Protocols
    PFs support the development and dissemination of clear clinical goals for in-clinic and SMBP-based BP targets, training on treatment protocols, and tools like EHR “dot phrases” to promote consistency.
  1. Engaged, Equipped Patients
    PFs work with practices to ensure patients are trained in SMBP procedures, use of digital tools, and have access to standardized take-home education and consistent follow-up instructions.
  1. Reliable Receipt of SMBP Data
    PFs help clinics assess and standardize how SMBP data is submitted, accessed, and documented—across CareSimple and other workflows. This includes technical training and workflow design.
  1. Use in Clinical Decision-Making
    PFs assist teams in building reliable systems for reviewing and acting on SMBP data. This includes standardizing communication processes, follow-up protocols, and medication titration workflows.
  1. Performance Monitoring and Continuous Improvement
    PFs support the use of dashboards and registry tools to track care team adherence to SMBP activities. They help clinics integrate these metrics into existing reporting, monitor trends, and recognize strong performance.
PF Role in Operationalizing the Key Driver Model According to the CHARMED protocol, PFs are expected to:
  • Tailor support based on each clinic’s SMBP capacity, regardless of whether they use CareSimple or other tools
  • Help clinics develop and implement SMBP workflows, especially when none are currently in place
  • Build systems around each key driver to sustain team-based, data-informed hypertension care
As stated in the protocol:
“The practice facilitation intervention is designed to help clinics integrate SMBP into routine care delivery using whatever tools and workflows best fit their clinic context.” (Protocol, p. 11)
“Facilitators will tailor coaching based on each clinic’s capacity, infrastructure, and preferred SMBP tools.” (Protocol, p. 22)
This model serves as a roadmap for PFs to guide structured, targeted coaching sessions and support clinics in creating the infrastructure necessary to use SMBP as an effective hypertension care tool.
About SMBP Devices and Funding
Securing validated home blood pressure monitors is essential for effective Self-Measured Blood Pressure (SMBP) programs in primary care. In California, there are several mechanisms to support device access, especially for low-income adults with hypertension. These include coverage through Medi-Cal, funding from public health departments and grants, and partnerships with managed care organizations.
  1. Funding Resources for SMBP Programs in California (partial list)
  • Primary care practices in California can use the following to support SMBP initiatives:
  • Medi-Cal Coverage for SMBP As of June 1, 2022, Medi-Cal (California’s Medicaid program) covers:
  • Automated BP monitors (HCPCS A4670)
  • BP cuffs (HCPCS A4663)
  • SMBP services such as training and interpretation (CPT 99473 and 99474)
These services can be billed through Medi-Cal Rx and are eligible under California’s hypertension care management reforms.
  • San Francisco Health Network (SFHN): Uses local public health funds and foundations to supply and distribute devices through clinics. (No public page, contact SFHN directly for more info.)
  • Local Managed Care Plan Collaborations: Some California managed care organizations (MCOs), such as LA Care and
  • Partnership HealthPlan of California, have funded SMBP devices directly or partnered with primary care clinics to integrate SMBP into quality improvement initiatives. Check with regional MCO representatives for funding opportunities.
Gold Coast Health Plan:
2. Examples of Exemplar Procurement Strategies
  1. San Francisco Health Network (SFHN)
  1. Created a centralized distribution system for devices using local public health funds and trained staff to support usage and data collection.
  1. Contact person:
  1. Ochsner Health (Louisiana)
  1. Deployed CareSimple Bluetooth devices funded through value-based incentives tied to hypertension outcomes.
    📄 Case study: https://phii.org/wp-content/uploads/2021/09/PHII-Report-on-SMBP_WebsiteVersion_9.14.2021.pdf
  1. Health Federation of Philadelphia
  1. Used HRSA hypertension funds to build a device lending program with training and follow-up from CHWs and MAs.
    📄 Case study: https://phii.org/wp-content/uploads/2021/09/PHII-Report-on-SMBP_WebsiteVersion_9.14.2021.pdf
These strategies show that with coordinated use of public programs, grants, and payer partnerships, primary care clinics in California can sustainably equip patients with the tools they need for successful hypertension self-management.
CUTTING
Task 9. Confirm SMBP model that will be used and Identify Key Roles
Work with the Champion to confirm the SMBP model the clinic will use or is using, and to identify and assign key roles for each step in the SMBP workflow to ensure clarity, accountability, and smooth implementation. This includes determining who will identify eligible patients, who will distribute and educate patients on device use, who will collect and document readings, and who will review and act on the data. Roles should align with staff capacity and clinic routines, and responsibilities should be clearly communicated and documented. Establishing defined roles helps create a reliable process and ensures that no critical steps are missed.
Assign specific roles to staff and clinicians. Examples of Roles Include:
  • SMBP Device coordinator
  • SMBP Trainer
  • SMBP Device manager
  • SMBP Technical assistance provider
  • SMBP Outreach coordinator
  • SMBP Data manager
Key roles worksheet
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