Improvement Insights: Blood Pressure Control
The Improvement Insight series highlights quality improvement projects within Southcentral Foundation’s Nuka System of Care. Each blog offers a detailed look at how SCF’s customer and community owned approach, data-driven strategies, and collaborative teams work together to initiate innovative solutions for current challenges.
Through a needs assessment done by Southcentral Foundation, cardiovascular disease was identified as one of the greatest health concerns of Alaska Native people. In response to not meeting the 75th percentile goal for the “Controlling High Blood Pressure” Healthcare Effectiveness Data and Information Set (HEDIS) measure, SCF formed a workgroup to determine ways to make improvements to blood pressure control for customer-owners.
The workgroup was formed with project members from various disciplines across SCF. This included primary care division leadership and operational partners, Integrated Care Team providers, organizational development improvement employees, and Data Services employees. The workgroup conducted a staff survey with integrated care teams in the Primary Care Service Division to gather feedback, understand challenges and current practices, and identify opportunities. The top opportunities for improvement identified were helping staff better understand and utilize data, standardizing blood pressure monitoring clinical practices, and exploring the utilization of home blood pressure monitors.
In August 2024, the workgroup created the “SCF Primary Care Best Practices for High Blood Pressure Control” to support staff with hypertension management. This resource focuses on
methodology, data utilization, action list management, and discipline-specific roles and responsibilities. All clinical staff were trained on this resource.
Also, between November 2024 and February 2025, the “Home Blood Pressure Monitoring PDSA (Plan-Do-Study-Act)” began in two clinics (8 provider teams) to create a standardized process, assess utilization, and gather feedback, to sustain long-term home blood pressure monitoring. This process showed that the use of home monitors significantly improves the management of hypertension.
Since May 2024, SCF’s score on the Controlling High Blood Pressure HEDIS benchmark has increased by 8.89% (61.67% to 70.56%). And as of May 10th, 2025, SCF has exceeded the target benchmark for the 75th percentile goal of 69.37.
If you would like more information on SCF’s improvement efforts for blood pressure control, or any other aspect of the Nuka System of Care, feel free to contact the SCF Learning Institute. Also, the upcoming Virtual Nuka Conference is an excellent opportunity to learn about SCF’s Nuka System of Care!
