Chronic Conditions - Key Activity 14


Foster Patients’ Ability to Self-Monitor Their Blood Pressure and/or Blood Glucose at Home


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination.


This key activity coincides with Key Activity 24: Develop System to Provide Remote Monitoring. Developing a system in conjunction with patients increases partnership between the clinician and the patient. It also assists patients with learning how to best monitor their condition and understand how different actions impact their health as a whole. This is especially important for diabetic patients, who would be able to see that their changing A1c is a direct result of regular self-monitoring. Encouraging self-monitoring allows for a greater degree of specificity and knowledge for clinicians. It also helps patients communicate their questions and concerns more effectively with their clinician.

Patient self-monitoring is important because it helps patients to better understand their condition and how lifestyle choices affect their overall health. For diabetic patients, it helps when adjusting their medication doses (depending on the type of medication that is being utilized). It also allows patients to communicate a more thorough picture of their condition with their clinician during regular visits. Self-monitoring may also be a source of motivation for patients when they can see direct correlative changes in relation to their actions.

Regular home patient monitoring promotes equitable outcomes by putting the patient at the center of their care structure. Regular diagnostic monitoring ensures that an accurate picture is obtained in regards to how effective a treatment plan is within the context of the patient’s everyday life. Independent of the unconscious biases and stressors that exist in a clinical setting, patients can instead be monitored in a safe and comfortable location.

Regular home monitoring may address some barriers to obtaining healthcare, such as lack of transportation. Regular monitoring provides regular updates, which also can encourage clinician teams to intervene skillfully and connect the patient to additional resources that could address any social or other care gaps.

Relevant health information technology (HIT) capabilities to support this activity include RPM technologies (including telehealth), care guidelines, registries, clinical decision support, care dashboards and reports, quality reports, outreach and engagement, and care management/care coordination.

(See Appendix E: Guidance on Technological Interventions.)

Registry data can support the identification of patients who are not meeting clinical goals. With focused outreach, care management resources can be leveraged to engage those patients in a conversation regarding their interest and ability to engage in remote monitoring technologies/telehealth as well as other modalities, as warranted by their condition. Asynchronous communication tools, such as patient portals and texting modalities, can also support these efforts.

Action steps and roles

1. Determine an agreed upon method and frequency with the patient for monitoring their blood pressure and/or glucose.

Suggested team member(s) responsible: medical staff and patient.

This may include, but is not limited to, RPM, journaling, etc. The method and frequency of monitoring should be evaluated regularly with the patient during their appointments. See Key Activity 24: Develop System to Provide Remote Monitoring for more information.


2. Work with the patient to ensure that they know how to properly utilize their blood pressure cuff and/or glucometer.

Suggested team member(s) responsible: medical staff and patient.

If possible, ask the patient to bring in their home blood pressure cuff to calibrate it with the clinic’s sphygmomanometer. One-on-one instruction during a nurse visit is a great opportunity to teach proper use. Training on proper blood pressure measurement technique and/or blood glucose measurement while in the clinic helps the patient to feel confidence while also correcting any improper techniques being utilized.

An example of this is Livingston Community Health, which utilized education to help patients feel adequately equipped to monitor their blood pressure at home.


3. Assist the patient to develop a network of support to help self-manage their chronic condition.

Suggested team member(s) responsible: medical staff, patient and caregiver.

A caregiver, family member or group (e.g., diabetes education or walking group, etc.) Groups are particularly beneficial due to their ability to generate relationships around a shared goal.


4. Assist the patient with understanding certain threshold diagnostics that they should be mindful of, which may warrant medical intervention (e.g., too high blood pressure, glucose value, etc.).

Suggested team member(s) responsible: medical staff.

Patients should be assisted with understanding when to reach out to their clinician with concerns and how to access care after hours for significantly abnormal diagnostics.


Example workflow

La Clinica de la Raza outlined in this case study how they implemented processes for patient self-monitoring of blood pressure.

Open Door Family Medical Centers chose to implement a blood pressure cuff loaner program in order to support a blood pressure patient self-monitoring program.

Implementation tips

  • The San Francisco Health Network developed a hypertension toolkit, which provides resources for staff (around self-measured blood pressure monitoring, including coaching for blood pressure cuffs, patient education materials, tools and frequently asked questions) and patients (including resources for home blood pressure cuff instructions for self-measuring blood pressure, logs, worksheets, action plans, healthy food information and more in English, Spanish and Chinese).
  • It may be beneficial to consider continuous glucose monitoring for patients. The Sonoma Valley Community Health Center utilized this method for patients who were not routinely checking their glucose levels while using traditional glucose meters.