Action Planning with Self-Monitoring Blood Pressure Improves Blood Pressure Control in Geriatric Patients

Practice Problem: Uncontrolled hypertension is a global healthcare problem. Hypertension is controlled in fewer than 1 in 5 people and has been attributed to premature deaths (WHO, 2021). PICOT: The PICOT question that guided this project was “In patients 65 years of age and older with uncontrolled blood pressure, how does a nurse-led blood pressure control program compared to standard of care improve blood pressure control at an outpatient clinic over 8 weeks?” Evidence: Five studies provided evidence that a nurse-led blood pressure decreased blood pressure results. The evidence supported the practice change of implementing a nurse-led blood pressure control program for patients 65 years and older to improve blood pressure control at an outpatient clinic. Intervention: The registered nurse developed joint goals with the patient based on their individual needs. The action assessed the patient’s treatment such as medication adherence and lifestyle changes (e.g., diet, exercise). The program linked self-monitoring blood pressure with individualized goal planning. Outcome: Due to the COVID-19 pandemic resurgence and an impending strike, timing of the project implementation was impacted. Department staffing and patient census was very low, which resulted in only two participants. Clinical significance was noted with one patient while the second patient did not have a decrease nor increase of their blood pressure at the 2 week follow up visit. Conclusion: Further evaluation of the change in practice over time may provide more evidence of clinical significance. A toolkit was developed and provided to the staff for future implementation and adaptation. ACTION PLANNING WITH SELF MONITORING BLOOD PRESSURE 4 Action Planning with Self-Monitoring Blood Pressure Improves Blood Pressure Control in


National, Global, Local, and Organizational Significance
The practice problem addressed in this project was uncontrolled hypertension. Patients with high blood pressure are at risk to develop heart disease and stroke, which are the leading causes of death in the United States (CDC, 2018). Nationally, 45% of the population or 108 million adults have hypertension or are taking medication for hypertension and only 24% of adults with hypertension have it under control (CDC, 2019). More men develop hypertension (47%) as compared to women (43%) and approximately 75% of the adults who have hypertension are 65 years and older (CDC, 2019). Globally, it is estimated that 1.13 billion people have high blood pressure, with two-thirds noted in low-and middle-income countries (WHO, 2021). Hypertension is controlled in fewer than 1 in 5 people and has been attributed to premature deaths (WHO, 2021).
The high blood pressure rate in adults in the San Bernardino County (SBC) in 2019 was 29.5% (San Bernardino County, 2021). The organization, in May 2020, had 52,556 adult patients, 65 years and older, diagnosed with hypertension. The target goal for controlled hypertension in the organization is 81% . However, only 75.5% were noted with controlled hypertension. There are measures to mitigate this practice problem that provides safe, ethical, quality care to the organization's geriatric population that this project addressed.

Patient, Society, and Quality Impact and Concerns
The patient's quality of life is impacted because high blood pressure has negative effects on the body. High blood pressure can lead to heart failure, heart attack, stroke, kidney disease or failure, chest pain, vision loss, sexual dysfunction, or peripheral artery disease (AHA, 2021).
Patients, as a result, have less physical activity, experience symptoms such as fatigue, pain, anxiety, and depression (AHA, 2021).
As the prevalence of hypertension continues to increase, societal concerns need to focus on increasing preventative care services to address the chronic condition (Kirkland, et al., 2018).
Improved access to these services to screen and treat hypertension will over time decrease societal costs as chronic conditions are managed better (Kirkland, et al., 2018). Health policy updates to broaden reimbursement for services such as health education classes, lifestyle counseling, and remote monitoring in the patients' homes will also motivate healthcare organizations to adopt and promote these type of programs (Carey, et al., 2018).
Poor technique with using the blood pressure cuff has been identified as a quality concern (Whelton, et al., 2018). Proper training and support for the patients to monitor their own blood pressure will ensure competency and promote engagement in the plan of care (Roy, et al., 2021).
Concerns with quality control have also been identified when patients report self-monitored blood pressure that they may withhold poor results or provide false results (Morrissey, et al., 2017;Whelton, et al., 2018). This puts the well-being and health outcome of the patient at risk.
Encouraging patients to have an active role in their own care may negate this concern.

Legal and Ethical Considerations
Inadequately assessing a patient's level of health literacy poses as a legal risk to the healthcare organization. Patients who are unable to understand the health information received from the health care providers cannot participate with full knowledge and comprehension in health-related decisions (Magnani, et al., 2018). An ethical consideration to be aware of is the potential for inequity in patient access to medical care and blood pressure medications (Whelton, et al., 2018). It was important to learn if the patient has health insurance or financial assistance and how they budget for their medical care and medications (Whelton, et al., 2018). This impacts the patient's compliance with the treatment care plan.

Financial Implications
The estimated, adjusted annual incremental cost for patients with hypertension is $131 billion per year higher as compared to non-hypertensive patients (Kirkland, et al., 2018). This has an impact to the healthcare system as this patient population has "$1920 higher annual adjusted incremental expenditure, 2.5 times the inpatient cost, almost double the outpatient costs, and nearly triple the prescription medication expenditure" (Kirkland, et al., 2018, p. 5). The costs in outpatient expenses, emergency department visits, and home health services for this condition have steadily increased (Kirkland, et al., 2018, p. 5). Uncontrolled high blood pressure has significant impact on economics, healthcare, and quality of life.

PICOT Question
The PICOT question was: In patients 65 years of age and older with uncontrolled blood pressure(P), how does a nurse-led blood pressure (BP) control program (I) compared to standard of care (C) improve blood pressure control at an outpatient clinic (O) over 8 weeks (T)? The participants were all adults 65 years of age and older at a medical office outpatient clinic with BP greater than 150/90 (Whelton, et al., 2018). The intervention was a nurse-led blood pressure control program that established self-monitoring blood pressure and an individualized action plan. The action plan assessed the patient's treatment plan such as medication adherence, lifestyle changes (e.g., diet, exercise), and barriers (Appendix A). For the comparison, standard care was defined as standard routine follow-up BP monitoring in the outpatient clinic with the provider. The outcome was increased blood pressure control (less than 150/90). For time, the measurement period for the evidence-based practice change was eight weeks.

Evidence-Based Practice Model
The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model was used to guide this evidence-based practice change project. The JHNEBP incorporated a "three-step process called practice question, evidence, and translation (PET)" (Dang & Dearholt, 2017, p. 1).
The practice question determined the problem of uncontrolled blood pressure in the patient population and stakeholders and an interprofessional team were identified for the project. The evidence was explored through an extensive literature search and resulted in three systematic reviews and two quantitative research studies, grades of 2 A's and 1 B, and 1 Level I, 1 Level II, and both grades of A, respectively. The translation involved the development of recommendations based on the evidence, implementation of the intervention, and evaluation of the outcomes. The model had several tools to facilitate the project. Each of the tools were important to the development of the practice question, analysis and synthesis of the literature evidence, level and quality grading, and the planning and implementation of the practice change.

Change Theory
Kotter's 8-step process was utilized as the change theory selected to guide the project and lead the change for implementation (Kotter, n.d.). The model was selected because the eight steps were logical and involved process steps that were easy to understand and follow (Table 1).
Steps 1 -4 involved communicating the significance of the problem to key stakeholders, gaining their support to implement the intervention, and building the interprofessional team. Steps 6 -8 dealt with the implementation, sustaining the changes made, evaluating the performance outcomes, and determining spread for system-wide change.

Evidence Search Strategy
The evidence search strategy involved using the following three databases: CINAHL Complete, PubMed, and Cochrane Library. The advanced search function was applied in each database. The following keywords were used to narrow the search: high blood pressure control or management AND self-monitoring blood pressure. The Boolean term of AND was used. The inclusion criteria were research articles that compared a nurse-led high blood pressure control program to the usual care and reported the effect on high blood pressure control. The exclusion criteria were non-English and pregnant women. In the CINAHL Complete database search, the filters applied were studies published between 2015 to present, English, and adults 65 years and older. In the PubMed database search, the filters applied were studies published between 2015 to present, English, adults 65 years and older, and article type as journal article, meta-analysis, randomized control trial, and systematic review. In the Cochrane Library database search, the filter applied was studies published between 2015 to present. Ancestry searches were also performed to identify additional potential studies for inclusion.

Evidence Search Results
The literature search resulted in 345 citations along with two ancestry searches. The articles were initially screened by reviewing the title and abstract. Studies were excluded if they did not meet the eligibility criteria. Records were also removed if they were identified as a duplicate from another database search. Studies had a more in-depth appraisal when titles and/or abstracts were not clear or did not have enough information to provide a clear decision for inclusion or exclusion. Twenty-two citations were eliminated that included 2 duplicate articles and 22 articles that included pregnant women or patients under the age of 18 years of age. An additional 169 articles had interventions and/or outcomes that were not applicable to the PICOT question and hypertension was not included in 133 articles; therefore, were excluded and reduced the number to 21 articles for a more detailed assessment. After further analysis, five studies remained for an in-depth review for their evidence level and strength. See Figure 1 for the PRISMA flow diagram.
From the five articles, two were quantitative research studies and three were systematic reviews. The JHNEBP Evidence Level and Quality Guide was used during the literature appraisal to provide ratings for the Level of Evidence and Quality Ratings. There are five evidence levels, and they were graded by the type of study design which include: 1) Level I: experimental study, randomized controlled trial, 2) Level II: quasi-experimental study, 3) Level III: nonexperimental study, 4) Level IV: opinion of respected authorities and/or nationally recognized expert panels, and 5) Level V: experiential and non-research evidence . There were three Quality Ratings of A, B, and C that indicated that the study was of high quality, good quality, and low quality or major flaws, respectively . One study had a Level of Evidence of I and the second study had a Level of Evidence of II. Both studies had Quality A ratings. For the three systematic reviews, two had Quality A ratings and the other one had a Quality B rating (Appendices B -E). As a result, the overall John Hopkins Quality Grade was A  and the Strength of Recommendation Taxonomy (SORT) Grade was A (Ebell, et al., 2004). For the SORT (Ebell, et al., 2004), it was a Level A because of the number of Level 1 quality studies that were evaluated.

Themes with Practice Recommendations
The synthesis of the literature provided relevant information to address the different parts of the PICOT question. The synthesis was comprised of five articles and are as follows: two quantitative studies (Kravetz & Walsh, 2016;Mattei da Silva, et al., 2020) and three systematic reviews (Glynn, et al., 2010;Mantovanil, et al., 2020;Tucker, et al., 2017). The two quantitative studies were primary research articles and utilized an experimental design, with one study having a quasi-experimental design and the second as a 3-arm randomized controlled trial (RCT) (Kravetz & Walsh, 2016;Mattei da Silva, et al., 2020). The RCT study and one of the systematic reviews compared the implementation of nursing case management to standard care (Mantovanil, et al., 2020;Mattei da Silva, et al., 2020) while the quasi-experimental study and another systematic review compared the team-based approach to standard care (Kravetz & Walsh, 2016;Tucker, et al., 2017). The primary care provider, nursing, and pharmacy are identified as members of the healthcare team. In the third systematic review, nurse-or pharmacist-led care was identified as one of the interventions that was evaluated (Glynn, et al., 2010). See Appendices C and D. There were four themes generated: (1) Blood pressure outcomes, (2) Additional patient outcomes, (3) Types of interventions, and (4) Presence of heterogeneity.

Blood Pressure Outcomes
Blood pressure outcomes were reported as measurements of the systolic and/or diastolic blood pressure values (Kravetz & Walsh, 2016;Glynn, et al., 2010;Mantovanil, et al., 2020;Tucker, et al., 2017) or blood pressure control (Mattei da Silva, et al., 2020). Blood pressure values less than 150/90 mmHg, in adults 18 years and older, were considered blood pressure control for this population (Mantovanil, et al., 2020;Mattei da Silva, et al., 2020;Tucker, et al., 2017). Statistical significance decreases in both the systolic and diastolic blood pressure readings were observed when care was provided by a registered nurse (RN) case manager, as a team approach from a health care team consisting of the provider, RN, and pharmacist, or during a blood pressure control program led by the nurse or pharmacist (Glynn, et al., 2010;Kravetz & Walsh, 2016;Mantovanil, et al., 2020;Mattei da Silva, et al., 2020). However, Tucker, et al. (2017) stated an improvement in the systolic blood pressure was shown while results for the diastolic blood pressure were similar between the intervention and control groups. Control groups were identified as usual care without self-monitoring.

Additional Patient Outcomes
Several other patient outcomes were measured in the five studies. Body mass index (BMI) and medication adherence were evaluated in two studies (Mantovanil, et al., 2020;Mattei da Silva, et al., 2020). The findings were varied where one study showed a reduction in BMI was greater as compared to the usual care group (Mattei da Silva, et al., 2020) while, in the systematic review, of the three studies that had evaluated BMI only one study showed a significant decrease (Mantovanil, et al., 2020). An improvement in medication adherence was identified in both studies (Mantovanil, et al., 2020;Mattei da Silva, et al., 2020). The duration of the studies ranged from six to twelve months and, because the DNP project was completed in eight weeks, these specific outcomes were not observed.

Presence of Heterogeneity
Heterogeneity was observed in all three of the systematic reviews due to the complexity and different type of interventions that could be applied by the nurse case manager to each patient as part of the patient's individualized care plan. As a result, meta-analyses could not be conducted to compare the results (Glynn, et al., 2010;Mantovanil, et al., 2020;Tucker, et al., 2017). It was observed, in the review of the individual studies, that self-monitoring combined with customized interventional supported lowered blood pressure results (Glynn, et al., 2010;Mantovanil, et al., 2020;Tucker, et al., 2017).

Practice Recommendations
Based on a comprehensive review of the literature using the PICOT question and evidence grading, there was strong evidence with consistent results that supported the practice change of implementing a nurse-led blood pressure control program for patients 65 years and older to improve blood pressure control at an outpatient clinic. The nurse-led blood pressure control program linked self-monitoring blood pressure with individualized goal planning. With nurse-led programs, blood pressure values and/or blood pressure control exemplified significant improvement across all five studies. All the studies were focused on patient outcomes and with the large number of Level 1 quality studies, the Strength of Recommendation Taxonomy (Ebell, et al., 2014) was considered Level A. The overall John Hopkins Quality Grade was A .

Setting
The organization where the DNP project was implemented is a medical center that has two hospitals and several ambulatory medical office buildings. The project was conducted in the Hypertension (HTN) nurse clinic. The outpatient department, called the Complete Care Department, is where the patients with chronic conditions such as uncontrolled high blood pressure were initially referred. The typical participant in the project was an adult, 65 years and older, who had a blood pressure greater than 150/90. The organization's mission is to provide high-quality, affordable health care services and to improve the health of the communities served. Their vision is to be a pioneer in medicine and research while striving for innovative care.
The medical center leadership team identified that patients with uncontrolled high blood pressure were at a higher risk for poor outcomes. The preceptor shared the concerns and expressed an interest in identifying potential solutions to improve outcomes for patients with uncontrolled high blood pressure. Organizational support for the project was confirmed through verbal approval from the preceptor after speaking with the Chief Nursing Officer, administrative leader, and department manager. These key stakeholders were engaged early in the beginning of project development stage to provide understanding, gain support, and receive approval to move forward with project planning.

Stakeholders
Using the JHNEBP Stakeholder Analysis Tool , the stakeholders were identified. The stakeholders for this project included the following: patients, Complete Care department manager, Complete Care Physician Leader, administrative leaders, RN case managers, Health Education department, Chief Finance Officer, Chief Operating Officer, preceptor, Chief Nursing Officer, Information Technology (IT), labor union stewards, scheduling/receptionist, public affairs/marketing, communications, security, the patients, and the Hypertension Committee.

Sustainability Plan
An evaluation of the outcome and sustainability measures were needed to determine if the changes were sustained. The data would continue to be shared and monitored monthly with the key stakeholders and the Complete Care department manager, physician leader, and staff to show whether progress and improvements are occurring. If the process, outcome, and sustainability measures met the set goals and continued a consistent positive trend, the project would be headed in the right direction for sustainability. In addition, support and buy in to change the practice from the staff and leadership was crucial to sustain the measures.

Interprofessional Collaboration
With the initiation of a project, building an effective interprofessional team began with identifying the right team members that provided the needed knowledge, expertise, and skills (Harris, et al., 2018). For this project, the interprofessional team consisted of the DNP student project manager, RN case manager, department manager, physician, health educator, Information Technology (IT), and preceptor. Additionally, communication and collaboration between the team ensured team effectiveness as quality, accurate information was shared in a transparent, bidirectional manner (Harris, et al., 2018;Landry & Erwin, 2015).

SWOT Analysis
A SWOT (strengths, weaknesses, opportunities, threats) analysis was performed on the DNP project. Strengths of the project were the skilled nursing staff and leadership support. There were several weaknesses identified and they were discussed with the department manager and other key stakeholders to address how the project would not negatively impact the RN's current workload. A staff meeting was planned to present the benefits of the project and how it would enhance their current work. And lastly, patients were outreached regarding the project and provided information on the nurse-led blood pressure control program (Appendix F).

Systems Change
The project had a micro level of systems change through the goal planning that the RN case manager jointly developed with the patients. The patients would be able to achieve improved blood pressure control from following the individualized action plans and selfmonitoring blood pressure at home. The individual patient data collected was aggregated and compared to the organization's benchmark data to determine the effectiveness of the nurse-led blood pressure control program to improve uncontrolled hypertension in the identified patient population. As outcome measures exemplify the benefits and results achieved with hypertensive patient's control, it has the potential to create a macro level system change within the clinic.
Success in managing uncontrolled hypertension has the potential to create a meso level systems, or system-wide, change with the different model of care delivery (Patient-Provider Partnerships) impacting the overall health outcome for identified patient populations. Executive leadership observe performance outcomes; thereby, support the spread of interventions in the other medical office buildings across the organization.

Project Objectives
The purpose of the project was to determine if implementing a nurse-led blood pressure control program for up to 8 weeks in the nurse clinic among patients, 65 years and older with uncontrolled high blood pressure, would result in improved blood pressure control. Control was measured by the blood pressure readings taken by the staff in the outpatient clinic and the aim was to achieve blood pressure levels of less than 150/90 mmHg, as indicated by the healthcare organization's hypertension treatment guidelines (Whelton, et al., 2018). The change in practice was the implementation of self-monitoring of blood pressure in the home along with individualized action planning that the RN case manager developed jointly with the patient.
The first objective of the project was to reach the goal of 90% of patients enrolled in the nurse-led program for blood pressure control, who are 65 years and older and have uncontrolled high blood pressure, achieve blood pressure levels of less than 150/90 mmHg by the end of Patients were instructed to take blood pressures readings twice a day, once in the morning and once in the evening, and keep a log of the readings for the RN case manager to review. The RN case manager called the patients every two weeks for follow up and addressed medications, blood pressure readings, and progress on agreed-upon goals. The RN case manager documented the conversation with the patient and the most current home blood pressure reading into the EMR.
The second objective was 90% of the electronic medical record (EMR) documentation by the RN case manager demonstrated a discussion regarding action planning and self-monitoring blood pressure occurred with the patient within two weeks of being enrolled into the nurse-led program. A chart review of the EMR was performed by the project manager for each patient to audit the RN case manager's documentation.
The third objective was 90% of the patients enrolled in the nurse-led program for blood pressure control, who are 65 years and older and have uncontrolled high blood pressure, reported taking their blood pressure twice a day, at least five days per week. The RN case manager asked the patient during the bi-weekly follow-up calls for the patients' blood pressure logs to assess whether the blood pressure was taken twice a day.
The fourth objective was 90% of the patients enrolled in the nurse-led program for blood pressure control, who are 65 years and older and have uncontrolled high blood pressure, have maintained blood pressure levels of less than 150/90 mmHg. The RN case manager will continue to follow up with the patient once a month through email and/or telephone. This frequent and routine touch points with the patient will encourage and support the patient to self-monitor their blood pressure and continue to sustain their plan and goals.

John Hopkins Nursing Evidence-Based Practice Model
The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model guided this evidence-based practice (EBP) project. The JHNEBP incorporated a "three-step process called PET: practice question, evidence, and translation" (Dang & Dearholt, 2017, p.1). In the evidence step, the analysis of the literature demonstrated that there is strong evidence to support the PICOT recommendation of a nurse-led blood pressure control program. The translation step guided the process to quickly implement the intervention over an eight-week period, evaluated its outcomes for success and effectiveness, and determined if it is a best practice to be spread across the organization (Dang & Dearholt, 2017, p. 1). A timeline with milestones and action plan ensured the project would stay on track. Project objectives were measurable and evaluated at baseline, 14 days, and 30 days of the start of the project. Updates to the leadership team, project team, and department stakeholders were provided at regular intervals. The project's outcomes, learnings, and next steps were discussed at the final meeting of the project.

Change Management Process
Kotter's process for leading change was used to guide the tasks involved in the project planning and implementation (Table 1). Steps 6 -8 in Kotter's model was used to build the implementation, evaluation, sustainability, and dissemination plans. Kotter's change theory was selected because each of the steps followed the project and change management process.
Having a defined timeline and goals to measure results to determine project success provided additional evidence to staff and stakeholders on the project's value and need for sustainability (Appendix G). The organization planned to utilize existing staffing resources for this project and any available resources to keep expenses as budget neutral for the department (Table 2).

Leadership Qualities and Skills
Being the project manager, this DNP student utilized transformational leadership skills to convey the vision for the project and motivate the team and other stakeholders towards the mission. A strong communication strategy was employed with the team. Key points of the project were presented to the team, managers, and staff (Appendix H). Communicating frequently, soliciting feedback and ideas to encourage active participation and engagement, and listening to concerns and responding quickly to address barriers were important to continue to align the team and key stakeholders towards the purpose and mission of the project.

Approval for the project was obtained from the USAHS Evidence Based Project Review
Council (EPRC) before submitting for approval from the organization's IRB committee. Next, the project was submitted to the organization's IRB committee for review and approval prior to the project go live date. Retrospective patient data for patients who had a documented blood pressure reading greater than 150/90 mmHg was extracted from the EMR as comparison data.
Comparison data resulted in 471 patients, 65 years and older, that had uncontrolled high blood pressure being identified for the medical office clinic. Pregnant patients were not included in the project. The documented data was collected from the EMR and the data collection tool. The data collected from the patients who received the intervention was aggregated (Table 4). There were four patients that were identified to receive the intervention during the 4-week period. The low participation from patients was due to several reasons. Because the approval process delayed the start, the project length was shortened, and the project occurred during the holiday season.
Patients were less likely to participate in action planning or follow up during this time. Since the project implementation period was shortened to four weeks instead of the originally planned eight weeks there was less time for the staff to outreach patients for an appointment at the nurse clinic. The organization also received a strike notification that impacted the entire nursing team.
The organization was experiencing a fifth surge for the COVID-19 pandemic where the clinic nurses were reassigned to assist in the inpatient units and COVID-19 testing site. This decreased the clinic staff. Also, patients were even less motivated to come into the clinic for follow up with the nurses.
Two of the patients did not meet the inclusion criteria because the baseline blood pressure reading at the nurse clinic visit was below the blood pressure level of 150/90 mmHg. As a result, these two patients were excluded from the project.
The project manager collected, analyzed, and stored the data in a secure computer that was password-protected and only accessible to the project manager. The data collection tool that the nursing staff documented the patient information on was located on a secured site that only the nursing staff, project manager, department manager, and preceptor had access to. The patients participating in the nurse-led program were given a unique identifier to keep private health information and demographics confidential and private. Missing data was noted but still included into the project data. An attempt to obtain missing data was made by review of the patient's EMR and contacting the patient.
Baseline data was collected for the blood pressure reading in the clinic, and again at 2 weeks and 4 weeks, and the RN or assigned healthcare practitioner recorded the information on a data collection tool (Appendix I). Two BSN-prepared registered nurses evaluated the data collection and action plan tools to ensure its face validity. The evaluation plan included the criteria for evaluation, the categories of measures, time points for data collection, type of data produced, statistical test used, and benchmarks for each measure ( Table 2). The data produced from the clinic blood pressure readings was considered continuous data because an actual number or value is produced. Paired t-tests analyzed the differences in the diastolic and systolic blood pressure readings before and after the nurse-led blood pressure program intervention for the group of participants. Statistical significance would be noted with p < .05. The analysis showed that statistical significance was not achieved, which would be expected with only two participants.
The clinically meaningful improvement data was more important to consider in this EBP project. The intent of the DNP project was to show the impact of the intervention on the clinical outcome of the identified patient population versus validating or invalidating the effectiveness of the intervention itself. Clinical significance typically would have been noted when the last three blood pressure readings are less than 150/90 to indicate that blood pressure control was established along with patient compliance with the agreed-upon action plan and self-monitoring of blood pressure. However, with the shortened project timeline, only one additional blood pressure reading was obtained by the nurse at the two week follow up visit for each patient. For the outcome measure, one of the two patients showed a decreased blood pressure reading below 150/90 mmHg. The blood pressure reading for the second patient did not show any difference from the initial reading. For the process measures, the RN case manager documented in both patient charts that a discussion regarding action planning and self-monitoring blood pressure took place. However, documentation on the patient reporting taking their blood pressure at home twice a day was missing in the EMR for both patients. This was a result of the staff noncompliance to document the information into the EMR. This will be reinforced by the department manager to remind the staff regarding the documentation and to monitor compliance through patient chart audits. For the balancing measure, overtime minutes attributed to the project were not incurred during the eight weeks. For the financial measure, there were no costs attributed to the email outreach to the patients since the project manager performed this function herself. Clinical significance is exhibited in one of the two patients with the noted decrease in the blood pressure reading below 150/90 mmHg. It can be extrapolated that with additional patients who receive the intervention and compliance in documentation from the nursing staff regarding the patients' progress with action planning, that clinical significance can be achieved from the intervention for the identified patient population. Although the second patient did not have a decreased blood pressure at the 2 week follow up, the reading did not show an increase in the blood pressure. Further evaluation of the change of practice at the 4 week follow up may provide more evidence of clinical significance for the patients.
For the sustainability measure, the registered nurse would continue with the intervention of SMBP and action planning to measure if the patients have maintained blood pressure levels of less than 150/90 mmHg. Based on the project results, a toolkit was provided to the department manager consisting of the action plan (Appendix A), instructions on how to complete the action plan (Appendix J), and a secure messaging script for the email outreach to the patients (Appendix K). The toolkit would provide the leadership team with the tools for future implementation and adaptation of the nurse-led blood pressure program to improve the program's outcomes and increase the likelihood for system-wide adoption. The organization's leadership team would decide, based on the clinical significance results of the patients' blood pressure readings, whether the practice change would continue as a standard operating procedure.

Impact
The project's goal was to reduce the high blood pressure for patients 65 years and older who had uncontrolled hypertension. The practice change was to introduce action planning combined with self-monitoring of blood pressure in the home. The project educated the nursing staff to the evidence supporting the practice change. The staff recognized the importance of the intervention. Before the project implementation, the nurses would measure the blood pressure and communicate with the physician regarding high blood pressure readings and request for medication treatment adjustments to aid in the hypertension control. Since the implementation, the nurses discussed with the patients regarding their action planning and identified individualized improvement goals such as medication adherence and lifestyle changes. The nurses in the clinic are supportive of the intervention and plan to continue with this practice.
Limitations identified are related to the timing of the project implementation and the COVID-19 pandemic. Also, the organization received a strike notice that would have impacted the entire nursing team. As a result, the department faced staffing challenges from increase sick calls and reassignment to the inpatient units and COVID-19 testing sites. In addition, the project was initially implemented during the holiday season, which contributed to low participation from the patients. It was recommended to the department manager and preceptor that the project would have increased chances for success if implemented during the spring or summer months and when the COVID-19 pandemic has improved. Ongoing follow up to the nursing staff from the department manager along with sharing the monthly data for controlled hypertension for the patient population for their specific medical office building will promote sustainability. The project will not be expanded at this time due to the lack of participation during the pilot.
However, the department manager will look at another pilot this coming spring or summer and will monitor the patient data for improved outcomes. The nursing staff expressed strong support for the intervention and discussed how to spread to other departments within the medical office building and across the organization. Based on their enthusiasm and strong support during the pilot, they will most likely continue to engage patients with making action plans and home monitoring of blood pressure. The nurses recognized and acknowledged that by improving the patients' uncontrolled hypertension it would have positive outcomes by reducing clinic visits, possibly reducing the use of medications, and improve their health through exercise and diet changes. The two patients were receptive to the nurses discussing action planning with them and engaging them what actions they could take to improve their lifestyle that would help reduce their blood pressure. A toolkit was put together to provide the tools and resources used during the pilot. The toolkit consisted of the patient action planning document, instructions on how to complete the action planning document, scripting for telephone and email outreach to patients regarding enrolling into the program, the data collection tool, and instructions on how to fill out the data collection tool. The patient action planning document also had embedded website links to patient education topics on high blood pressure, monitoring blood pressure at home, following a DASH diet, monitor weight, and increasing physical activity.

Dissemination
The project findings were shared with the department manager and preceptor. Both individuals recognized the limitations of the project and supported the toolkit development as an additional resource for future use. The project findings were presented to the organization's nursing leaders and other interprofessional team members. A meeting to present the project findings with the organization's nursing leaders and other interprofessional team members was scheduled the following month. It was shown as a presentation in PowerPoint format and shared the project objective, evidence, toolkit, trends, findings, and recommendations. The abstract submission was submitted at the organization's national nursing conference, Alpha Alpha Alpha Chapter Sigma USAHS SON DNP Scholarly Project Symposium, and in the SOAR@USA database. SOAR@USA is the institutional repository that collects scholarly works of students, staff, and faculty for the University of St. Augustine. Within the professional community, the findings will be submitted for abstract submission at the annual conferences for the American Academy of Ambulatory Care Nursing (AAACN)'s annual conference in the coming summer.
The AAACN is the professional organization for ambulatory care and is an appropriate choice to disseminate the information and learnings to spread to other ambulatory clinics and locations.
Peer reviews of podium and/or poster presentations prior to submitting to the professional organization were conducted.

Conclusion
The DNP project objective evaluated if the intervention of a nurse-led blood pressure control program would affect the blood pressure control in patients 65 years and older who had uncontrolled blood pressure. Strong evidence in the literature supported that self-monitoring blood pressure along with patient-specific co-interventions will improve blood pressure control.
Uncontrolled high blood pressure in geriatric patients has negative impacts to their health outcomes and quality of life. This has a downstream affect and financial implications to the patient, family, and healthcare system. The John Hopkins Nursing Evidence-Based Practice model was an effective resource to appraise and synthesize the existing evidence and research.
Kotter's change theory provided guidance to the change process through its eight steps for leading change. The evidence searches through three databases ultimately produced five results that provided the strong evidence to support the DNP project. It was observed that multiple interventions along with self-monitoring of blood pressure were employed towards controlling high blood pressure in patients.
The DNP project setting was implemented at an outpatient department where patients with high blood pressure were identified. The medical center leadership team recognized that a gap in blood pressure control existed in their patient population. Interprofessional collaboration between the stakeholders and professions was essential and each team members' input and perspective helped towards identifying barriers and working together towards solutions. The SWOT analysis identified several weaknesses and threats for continuously monitoring. The project timeline outlined the project tasks to be completed and an evaluation plan, with the project objectives, that aided to determine the effectiveness of the intervention and project.
Due to several limitations, the project implementation was impacted, which resulted in only two participants in the pilot. Clinical significance was noted in one patient while the second patient did not show an improvement nor worsening of the blood pressure reading. As a result, further evaluation of the intervention over time with more participants may provide indication of clinical significance. At the project close, a toolkit with resources was provided to the leadership team for future implementation. The findings were also disseminated at a DNP scholarly project symposium, in the university's scholarly resource database, and an abstract for a professional organization's annual conference was submitted.
Jr (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension (Dallas, Tex. : 1979), 71 (6) Enlist a volunteer army • Identify champions and early adopters that support the project and will help to lead the change for implementation.

5.
Enable action by removing barriers • Involve and engage staff and managers in the process and the project in the beginning. • Provide opportunities to listen and respond to questions and concerns with timely follow up to build trust with the staff. 6.
Generate short-term wins • Develop milestones and then celebrating as milestones are accomplished motivates the team and the stakeholders. • Identify low hanging fruit that can be easily accomplished and celebrated. 7.
Sustain acceleration • Ensure that a change occurs quickly in order to sustain the sense of urgency and keep the momentum and energy around the project. • Through frequent updates and feedback from the staff, make any adjustments needed. 8.

Strengths
• Improve quality of care and reduce uncontrolled BP rates Your physician would like you to come in to have your blood pressure checked at the nurse clinic. We would like to schedule an appointment for you to come in to see one of our nurses.
Please call us at (909) 477-3853 and leave a message with your name, medical record number, and a phone number you can be reached at. A nurse will call you back to schedule an appointment with you. Sincerely, The Rancho Cucamonga Medical Office Building Care Team Option 2: Your physician is recommending that you have your blood pressure checked at the nurse clinic.
We would like to schedule an appointment for you to come in to see one of our nurses. Please call us at (909) 477-3853 and leave a message with your name, medical record number, and a phone number you can be reached at. A nurse will call you back to schedule an appointment with you. Sincerely,

The Rancho Cucamonga Medical Office Building Care Team
Phone Call Script (speaking with patient/caregiver) Option 1: