General Guide for High Blood Pressure Screening, Referral, and Follow Up
This general guidance is applicable to many community settings. Specific information regarding your setting may need to be obtained from local medical advisors. A high blood pressure control program has four basic components. - Screening. Blood pressure screening may take place at a specially organized event or at other gatherings. At either kind of screening, trained volunteers measure blood pressures. Screenings serve two purposes: (1) to detect persons with elevated blood pressures and assist their entry into the health care system; and (2) to monitor the pressures of those who are already aware of their HBP and undergoing treatment in order to continue to control their blood pressures.
- Referral. During screening, those with elevated readings are referred to a doctor or clinic for further evaluation and diagnosis. If a subsequent reading is normal or only slightly elevated, the person may be referred to a later screening in 6 months or a year.
- Follow up and tracking. After screening, program leaders contact individuals with elevated readings or the doctors or clinics to whom they were referred to ensure that further evaluation took place. Long-term tracking can involve continued patient contacts. Programs in religious congregations and other membership groups have the capacity to keep track of patients by monitoring their blood pressures at subsequent screenings.
- Education and support. Controlling high blood pressure usually means learning new habits such as taking HBP medication daily, losing weight, and eating a healthy diet. Support groups, nutrition classes, and other educational sessions can help patients adhere to treatment and are important parts of a HBP control program.
The Screening Process The traditional community screening process is usually divided into three stages: registration, measurement, and referral and counseling. - Registration station. Ask the person to be screened to fill out a form with name, address, and telephone number and to sign a statement giving permission to have his or her blood pressure measured. Registration forms often ask for other relevant health information. (Sample registration form--PDF file, 36 K) After registering, the person proceeds to a waiting area. Some programs take advantage of this waiting time to show educational films or provide information on high blood pressure.
- Measurement station. Blood pressure measurement may require one or several tables, depending on the size of the group and the number of screeners. Ideally, It should be far enough away from the busy registration and waiting areas to ensure confidentiality. Ask the person to sit down and roll up a sleeve, if he or she is wearing a long-sleeved shirt. The table should be high enough for the person to rest an elbow at heart level (desk height). Choose the appropriate cuff size (i.e., child, adult, large adult), and measure the blood pressure according to established guidelines. Tell the person what their BP number is, and enter the reading on the registration form as well as on a card for the person to keep.
- Referral and counseling station. Anyone who has an elevated blood pressure reading at the screening station should be sent to the referral station where a health professional:
- Rechecks the blood pressure.
- Provides information and advice.
- Makes referrals to a doctor or clinic for a repeat measurement.
- Persons with marked BP readings (characterized by severe BP elevations >180/120 mmHg) should be sent to a hospital emergency room for further evaluation.
Many businesses and other workplaces use automated blood pressure screening machine as a component of their blood pressure control program. Besides measuring blood pressure, some of these automated stations also measure weight and calculate body mass index (BMI) based on height, explain the meaning of the measures, recommend corrective action (including seeing a doctor) if the readings are high. The Stroke Belt project in Mississippi showed positive results from the deployment of these automated machines in both public and business locations. Date, Time, and Location Schedule the screening on a day and time when most people will be able to attend. For example, you may want to have the screening follow a worship service or take place during another special event that is popular with the congregation. When setting up the screening area, try to give it an orderly, professional appearance-labeled screening stations, name tags and perhaps special armbands for volunteers, signs to reinforce verbal directions, and a well-defined waiting area with reading materials. All of these can help give both participants and volunteers a sense of confidence in the screening process. Promotion Remember to announce the date, time, and location of the screening several weeks before the event. In religious congregations, announcements can be made during worship services, in the congregation's bulletin, and perhaps by an exhibit or poster. The clergy plays a crucial role in promoting the program. Ideally, he or she will include high blood pressure control program announcements in messages to the congregation several weeks before the screening. Remind members to bring other family members who may not regularly attend services to the screening. Educational Materials The BP screener should spend a few minutes with each person explaining what the blood pressure measurement means and answering any questions. This interview should be reinforced with a fact sheet or other hand out on high blood pressure. Persons with elevated blood pressures should be given additional materials that have a patient education orientation. Follow-Up Activities Following up the screening with individual contacts, education, and support is a vital part of high blood pressure control. The weeks and months after screening are the times when many people with high blood pressure drop out of treatment. A carefully planned and implemented follow-up program may help some people stay in treatment. Follow-up involves patient tracking, education, and support. Tracking includes maintaining regular contact with people with elevated readings to encourage them to make and keep appointments with a doctor or clinic. Education addresses the how's and why's of controlling high blood pressure, including making necessary dietary changes, quitting smoking, exercising regularly, and taking prescribed medicine. Support involves helping people with high blood pressure adhere to long-term treatment. Support groups, consisting of people with high blood pressure who meet regularly to share problems and solutions may be helpful.. Patient Tracking Studies show that most people referred to doctors because of an elevated blood pressure measurement (referees) do keep their appointments if someone contacts them shortly after a screening. The planning phase is the time to determine who will contact referred persons and how such follow-up will be conducted. Some programs have used the methods described below. - Telephone. Volunteers call referees and remind them of the importance of making and keeping appointments. (Sample telephone guidelines--PDF file, 36 K)
- Mail. A letter or postcard is sent to referees to remind them to make and keep an appointment. Sample reminder letter.
- Mail-back card. A postcard requesting specific information is given to referees at the screening. They take this card with them to the doctor or clinic, where it is filled in and then mailed back to the program by the patient or doctor.
- In-person visits. In some congregations, volunteers sometimes visit referred people in their homes to encourage them to see a doctor for diagnosis.
- Rechecks. Setting up sites for monitoring blood pressure and support counseling offers yet another way of encouraging referred individuals to see a doctor.
Regardless of the method used, the following steps should be taken shortly after the screening. - Coordination. Get the screening forms to the volunteers making the follow-up contacts, and discuss timing. Make sure each volunteer has a copy of the follow-up guidelines.
- Recordkeeping. Keep track of contacts.
- Problem Solving. Decide how best to handle cases in which you cannot make contact, basing your decisions on the established guidelines.
Forms and Filing After the screening event, the forms completed for each person screened should be returned to the volunteer responsible for follow-up. File separately those forms completed for people with elevated readings to make follow-up contact easier. It may be useful to file them by the date on which a reminder will be sent—in the next few days for those referred to a doctor or clinic or in 6 months to a year for those referred to a second screening. Keep track of follow-up contacts and their results. Some programs reserve space on the original screening form to record this information; others use separate forms. It is useful to have enough room on the form to keep track of attempts to reach people. Keep a separate file for those persons contacted who have not yet seen a doctor and therefore need to be contacted again. Education Religious congregations and other membership groups are ideally situated to offer education and support programs. Most have groups that meet regularly during the week and the logistical and communications systems to support such activities are in place. In some cases, HBP control activities can even be incorporated into existing groups. For example, a meal function could feature food prepared from recipes in the DASH Eating Plan, a group for seniors could view a film on high blood pressure at one meeting and organize a walk at another; and an auxiliary could organize a support group. During the planning phase, program coordinators will determine whether to arrange for in-house health education programs, refer patients to outside resources, or use a combination of approaches. In-house programs may consider the following topics: - Weight Loss. Losing weight is beneficial for overweight people with high blood pressure. A weight loss program in a religious congregation in Baltimore consisted of eight 2-hour sessions that included diet counseling and exercise. Many participants reduced both weight and blood pressure. Weight loss groups can be organized in-house, or people can be referred to community resources.
- The DASH Eating Plan. Research shows that the DASH Eating plan emphasizing lowering salt and sodium can provide large reductions in BP and may prevent high blood pressure. Cooking classes and demonstrations may be organized as part of other activities.
- Smoking Cessation. Smokers, even if they do not have high blood pressure, are two or three times more likely to have heart attacks than are people who do not smoke. Nobody with high blood pressure should add to his or her cardiovascular risk by smoking. Go to the Web site of the U.S. Surgeon General for the latest information to help smokers quit. Religious congregations in the Louisiana and Virginia Stroke Belt projects promoted in-house programs to help to encourage and help smokers quit.
- Exercise. Walking, jogging, swimming, and other kinds of regular exercise help prevent and control high blood pressure.
- Medicine. Religious congregations and others can conduct educational sessions on prescribed medicines and their proper use. These sessions can present suggestions for establishing communication with the doctor about prescribed medicines; tips for remembering to follow drug regimens; and guidelines for handling problems associated with taking medicines (e.g., missed dosages, side effects, and drug interactions).
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