Implementing a Self-measured Blood Pressure Monitoring Process

Practice Problem: Because of the prevalence of hypertension worldwide, it is prudent for all patients to have the knowledge and ability to self-monitor their blood pressure. Patients monitoring their own blood pressure and communicating the readings with healthcare providers facilitates a more comprehensive plan of care. PICOT: The PICOT question that guided this project was: In adults 18-90 years old with primary hypertension (P), will a self-measured blood pressure monitoring that includes a monthly telehealth visit with a provider (I), compared to blood pressure monitoring at routine office visits (C), decrease patients' systolic blood pressure readings by five mmHg (O) within 8 weeks (T)? Evidence: Research shows that self-measured blood pressure monitoring reduces blood pressure, possibly because treatment adherence is improved due to daily monitoring and reporting the reading to a provider. Intervention: Twenty participants took their blood pressure at home with a verified monitor and entered the readings into the patient portal for the provider to review for 8 weeks. Pre and postproject blood pressure readings were analyzed for home monitoring effectiveness. Outcome: A two-tailed paired samples t-test was used to show that the mean of the pre-project systolic blood pressure was significantly higher (143.60 mmHg) than the mean of the postproject systolic blood pressure (130.50 mmHg). Clinical significance was observed by lower systolic blood pressure readings of the hypertensive participants by the end of the project. Conclusion: By monitoring at home daily, the patient is aware of their blood pressure readings and understands when treatment changes are necessary. This increases patient engagement in the self-care of hypertension while reducing their blood pressure. IMPLEMENTING SMBP PROCESS 4 Implementing a Self-measured Blood Pressure Monitoring


Process
Elevated blood pressure or hypertension (HTN) is one of the most common chronic conditions in adults that damages blood vessels and leads to cardiovascular disease (NCD Risk Factor Collaboration, 2017). Known as the silent killer, hypertension is often the first chronic disease in patients that creates a domino effect of other conditions with devastating consequences (Department of Health and Human Services [HHS], n.d.). Approximately half of all adults in the United States, or 116 million people, have systolic blood pressure greater than 130 mmHg or diastolic blood pressure greater than 80 mmHg (Centers for Disease Control and Prevention [CDC], n.d.-a). Unfortunately, people are often unaware of when their blood pressure (BP) is elevated; therefore, frequent monitoring is recommended (Whelton et al., 2018). Adequate management of hypertension by healthcare professionals and the individual is essential to avoid health complications and improve quality of life (World Health Organization [WHO], 2022).
Self-monitoring of BP and follow-up visits with a clinician can promote quality management of hypertension. These actions will help prevent the negative cascading effect of hypertension (Whelton et al., 2018).

Significance of the Practice Problem
There are 1.3 billion hypertensive people globally, with approximately 720 million not receiving proper treatment (WHO, 2022). Cardiovascular disease is the leading cause of death in the United States (United Health Foundation, 2022). In 2018, approximately 96,000 deaths were attributed to hypertension in the United States (CDC, n.d.-a). Research shows that an estimated $131 billion is spent yearly on hypertensive patients compared to those without hypertension (Kirkland et al., 2018). A study from the State of Kentucky reports that 40.9% of its population has hypertension, with 11,345 deaths in 2020 attributed to heart disease (CDC, n.d.-b;United Health Foundation, 2022).
Because there are often no signs of increased BP, patients may be unaware of the damage to their blood vessels. Even with patients aware of their chronic hypertension, routine tracking of BP is integral to a successful plan of care (WHO, 2022). This is especially true as BP progressively increases with age. In 2017, 77.3% of people 65 and older in the US had hypertension (CDC, 2019). Before 2017, the threshold for a hypertension diagnosis was blood pressure consistently 140/90 mmHg or higher (Department of Health and Human Services, n.d.). After extensive research on the damage of hypertension, the ACC and the AHA published a clinical guideline to change the hypertension threshold to 130/80 mmHg or greater (Whelton et al., 2018).
At most primary care visits at a large ambulatory clinic in central KY, the patients have their BP taken before meeting the clinician. If the reading exceeds 140/90 mmHg, another BP is taken in 5 minutes. This additional reading ensures that the elevated BP is not because of walking from the parking garage to the clinic. However, this practice does not account for white coat hypertension. Abnormal BP readings in the clinic compared to a normal BP measured outside the clinical setting are called white coat hypertension (Johansson et al., 2021). To make this comparison, the patient must take their BP at home. Because of the prevalence of hypertension, it is prudent for all patients to have the knowledge and ability to self-monitor their BP. A self-measured blood pressure (SMBP) protocol would be beneficial in identifying patients that have not been diagnosed yet with hypertension and patients diagnosed with hypertension but need additional treatment.

PICOT Question
The PICOT question that guides this evidence-based project is: In adults 18-90 years old with primary hypertension (P), will a self-measured blood pressure monitoring that includes a monthly telehealth visit with a provider (I), compared to blood pressure monitoring at routine office visits (C), decrease patients' systolic blood pressure readings by five mmHg (O) within 8 weeks (T)?
The conceptional definition for each component is a population (P) of 18-90 years old in a primary care clinic at a large teaching hospital; the intervention (I) is self-measured blood pressure readings reported daily via the organization's patient portal and monthly telehealth visits with a provider; the comparison (C) is the usual care of attending an appointment in the clinic with a blood pressure reading done by the staff; the desired outcome (O) of the intervention will be a decrease by five mmHg in the systolic measurement; the timeframe (T) for the data collection is 8 weeks. The current practice of the providers in the clinic is to encourage the patients diagnosed with hypertension to monitor their BP at home and report the readings at the next office visit. However, there needs to be a process to assist in doing this. This change project will initiate an SMBP protocol among 20 patients in the clinic to ascertain the effectiveness of daily reporting of BP readings to the provider and monthly follow-up visits.

Evidence-Based Practice Framework & Change Theory
DNP projects require a framework that guides the process of translating the EBP into practice. This project utilized the Johns Hopkins Nursing Evidence-based Practice (JHNEBP) model (Dang et al., 2022). The JHNEBP model focuses on a three-step process called PET: practice question, evidence, and translation (Dang et al., 2022). The purpose of this model is to provide the latest research findings that support best practices (Dang et al., 2022). For this project, the process plan was as follows: Step 1 Practice Question An interprofessional committee was organized, and meetings were held to determine the need for change from current BP management practices. Stakeholders were identified at this time. From this information, the PICOT question was developed.
Step 2 Evidence A rigorous search was done for evidence for data pertaining to the SMBP monitoring.
The themes that were identified were a reduction in BP readings, telehealth visits, and daily readings increased treatment adherence. Each article was appraised for quality and information relevant to the project. Relevant articles were chosen, and the findings were synthesized for the best practice recommendations.

Step 3 Translation
Clinic-specific recommendations, such as SMBP with telehealth follow-up visits, were identified by the project committee that correlated with the organization's mission. Support from the organization's leadership was obtained. Once the project was completed, the outcomes were disseminated to the organization and other entities.
The Diffusion of Innovation (DOI) change theory was used for this project. In 1962, E.M.
Rogers developed this theory to explain how an idea spreads over time in a specific population (Rogers, 1983). Effective communication is required to create momentum for an idea to be adopted by others (Binji, 2020). This change theory works well with the project as the patient monitors their blood pressure and reports to the provider via the patient portal. Lower BP readings confirm that the SMBP protocol assists in creating a positive outcome for patients by managing their hypertension.

Evidence Search Strategy
The evidence search strategy for this project involved using three databases: CINAHL Complete, PubMed, and Joanna Briggs Institute EBP Database. In the CINAHL Complete database, the terms searched with the Advanced Search filter were "home blood pressure monitoring" OR "self-measured blood pressure or smbp" OR "self-monitoring blood pressure" OR "Out of the Office Blood Pressure Monitoring" AND "hypertension or high blood pressure" AND "patient portal or telemedicine." The inclusion filters of publishing date from 2017-2022, English language, abstracts, and peer reviewed. The filters "All Adult" and "USA" were chosen after the initial search results to narrow the search even more. In the PubMed database, "home blood pressure monitoring" OR "self-monitoring blood pressure" OR "self-measured blood pressure" AND "patient portal OR telemedicine." The inclusion filters used were 5 years, English, abstract, randomized clinical trial (RCT), and adult:19+. Lastly, the Joanna Briggs Institute of EBP database was used. The search words were "home blood pressure monitoring AND hypertension." An Advanced Search filter narrowed the dates to 2017-2022 and searched for articles with abstracts.

Evidence Search Results
The evidence search provided 278 articles to be reviewed. The abstracts of these articles were investigated to ascertain the relevance of the evidence to this translational project. Articles were discarded due to duplication, the need for more quality of the study, and irrelevance to the PICOT question. The full texts of the articles whose abstracts passed the first review were obtained for a more thorough inspection. The JHNEBP criteria were used to grade the quality of the final group of articles analyzed (Dang et al., 2022). The JHNEBP table provides a hierarchy of evidence based on the study type used to retrieve the data and its reliability. The evidence levels range from level I, which includes RCTs, to level V, which includes literature reviews and case reports (Dang et al., 2022). The evidence grades range from A to C, based on the quality of the results (Dang et al., 2022).
After reviewing and grading 61 full-text articles, 15 were chosen for this project due to their pertinence and strong evidence grades (see Figure 1). There are nine primary research articles, two systematic reviews with a meta-analysis, two systematic reviews without a metaanalysis, and one position statement by the American Heart Association and the American Medical Association (see Appendices A, B & C). Six of the primary research articles were JHNEBP quality rated I/A because the RCTs produced thorough scientific evidence and definitive conclusions regarding SMBP (Margolis et al., 2018;McManus et al., 2018McManus et al., , 2021Tzourio et al., 2017;Yatabe et al., 2021;Zhang et al., 2021). One cohort study (III/A) was chosen because the participants utilized SMBP and input their readings into a patient portal (Lee et al., 2022). This study re-analyzed data from an earlier RCT to ascertain how the clinician responded to their alerts in the patient portal. One mixed method designed Study (II/A) and one qualitative study (III/A) were selected because of the extensive evidence presented (Allen et al., 2019;Beran et al., 2018). Lastly, the position paper was chosen because it is the gold standard for self-management of high blood pressure (Shimbo et al., 2020). The HHS created a website based on these recommendations to assist patients and clinicians in implementing SMBP programs throughout the United States (HHS, n.d.)

Diagnosis of Hypertension
Many studies included data on the use of ambulatory BP measurement to diagnose hypertension (Guirguis-Blake et al., 2021;Shimbo et al., 2020;Viera et al., 2021). Ambulatory BP measurement is done by placing a cuff on the patient for 24 hours, which collects readings at set intervals (Shimbo et al., 2020;Whelton et al., 2018). While this may be considered the Gold Standard for diagnosing HTN, some patients cannot tolerate having their BP taken consistently over 24 hours (Shimbo et al., 2020;Viera et al., 2021;Whelton et al., 2018). SMBP is less restrictive to the patient and provides data over weeks (Beran et al., 2018;Guirguis-Blake et al., 2021;Shimbo et al., 2020;Viera et al., 2021;Whelton et al., 2018). Often patients have high BP readings only while at an office visit. SMBP can be used to determine if this is true HTN or white coat HTN (Shimbo et al., 2020;Viera et al., 2021;Whelton et al., 2018).

SMBP with Additional Interventions
Several studies identified that collaboration between the patient and the provider, along with SMBP, often resulted in a better outcome than SMBP alone (Beran et al., 2018;Lee et al., 2022;McManus et al., 2018McManus et al., , 2021Tucker et al., 2017;Whelton et al., 2018). Specifically, combining a scheduled telehealth visit to discuss blood pressure trends results in identifying barriers to self-managing HTN. During this telehealth visit, lifestyle modifications and medication adjustments can be timely addressed (Beran et al., 2018;McManus et al., 2018McManus et al., , 2021Tucker et al., 2017;Whelton et al., 2018;Yatabe et al., 2021). Another intervention that increases patient engagement and decreases the chance of sustained HTN is electronic reporting of daily BP readings to the provider. With this information, the provider is alerted that the BP pressure is out of parameters, and adjustments can be made quickly (Beran et al., 2018;Lee et al., 2022;McManus et al., 2018McManus et al., , 2021Shimbo et al., 2020;Tucker et al., 2017).

Practice Recommendations
The strength of the research reviewed included evidence levels I, II, III, and IV, with an A quality level. The high-caliber quality and strength of evidence answer the PICOT question by identifying that SMBP reduces high BP (Beran et al., 2018;Guirguis-Blake et al., 2021;Lee et al., 2022;Margolis et al., 2018;McManus et al., 2021;McManus et al., 2018;Shimbo et al., 2020;Tucker et al., 2017;Tzourio et al., 2017;Yatabe et al., 2021;Whelton et al., 2018;Zhang et al., 2021). Initiating an SMBP protocol in a primary care clinic that includes home BP monitoring machine validation and education on proper techniques for taking the BP is beneficial to patients with high blood pressure (Guirguis-Blake et al., 2021;Margolis et al., 2018;McManus et al., 2018McManus et al., , 2021Shimbo et al., 2020;Whelton et al., 2018). Daily BP readings recorded by the patient directly into their chart through the patient portal provide BP trends that assist the clinician in determining the proper treatment. An alert will notify the clinician if BP readings are out of range (Lee et al., 2022).
Monthly telehealth visits with the provider offer the opportunity to educate and make necessary changes to medication (Beran et al., 2018;Margolis et al., 2018;McManus et al., 2018McManus et al., , 2021Yatabe et al., 2021). The patient being directly involved in their care increases patient engagement and medication adherence (Beran et al., 2018;Margolis et al., 2018;Yatabe et al., 2021). The illustration in Figure 2 shows the symbiotic relationship necessary for successful SMBP monitoring (CDC, 2020). This collaboration between the patient and the provider creates effective patient-centered care (Margolis et al., 2018;Tucker et al., 2017).

Setting, Stakeholders, and Systems Change
The setting of this DNP scholarly project was a small primary care clinic affiliated with a large teaching hospital. The patients' ages range from 21 to 100 years old. The services provided in the clinic include managing acute and chronic medical conditions, annual health exams, health promotion, disease prevention, and patient education. The staff consists of two physicians, one nurse practitioner, one registered nurse, one medical assistant, and one registration clerk. The clinic sees approximately 50 patients each week.
The needs of the organization were discussed with stakeholders to determine if the DNP Evidence-based Project was appropriate. Over 50% of the clinic panel has been diagnosed with HTN. A discussion with the providers revealed that this patient population is asked to annotate BP readings on paper logs, but many of these patients do not provide this information back to the staff. A way to report the BP readings directly into the chart would benefit the patient and the provider.
The stakeholders in this project are primarily the clinic patients and the providers. With an established protocol of SMBP that includes reporting BP readings via the patient portal, the providers have sufficient data to treat this chronic condition appropriately. Other stakeholders are the chief nurse executive for ambulatory care and providers in the cardiac clinic that may also be treating the patient. Intercollaboration of care is crucial in improving the quality of care by coordinating with all clinicians that may be treating the patient (Melnyk & Fineout-Overholt, 2019). The organization's mission is to commit to patient care, education, and research. The enterprise supported this project by extracting data from the EHR by the Center for Clinical and Translational Science department. Sustainability is feasible with staff training to include SMBP as part of their HTN plan of care.
A SWOT analysis (see Figure 3) was performed to identify internal and external opportunities and concerns. It was essential to understand the project's strengths compared to weaknesses. The main strengths of the SMBP project were patient engagement in their care and positive outcomes with their chronic disease. This project also provided the opportunity to develop an SMBP protocol that could be used organization-wide and add revenue for increased telehealth visits. The weaknesses that were exposed involved internet and patient portal access.
Threats to the project included inconsistent patient adherence to the SMBP protocol and taking their medications as prescribed. This micro-system change project enabled the patient to become more active in their care and strengthened their communication with the provider. In turn, the provider gained essential data to guide the treatment needed for a positive outcome.

Implementation Plan with Timeline and Budget
The JHEBP model provided tools to translate the evidence into an action plan (See Appendix D). With these tools, the following plan was developed:

JHEBP Action Plan
Care Team Actions 1. Initiate standardized training of clinicians to take BP measurements accurately one week before the project (See Appendix E). 3. Staff instructed the participant to use the patient portal to record daily BP readings on day 1 of the project. 4. Initial BP readings were recorded at the office on day 1 of the project.

Telehealth appointments with a clinician to review BP readings and adjust medications
were scheduled for week 4 of the project.
6. BP readings were recorded at the office on week 8 of the project.
The BP data collected in the office at the beginning and end of the project were analyzed to ascertain the significance of SMBP in managing HTN. Four main objectives guided the implementation plan for the project: 1. Selection of 20 adults diagnosed with HTN from the internal medicine clinic by EHR random selection by the end of week 4 of NUR 7802.
2. Attained access to the patient portal for 100% of project participants, and each had a validated home BP monitor to begin data collection by the end of week 5 of NUR 7802.
3. Retrieved data of 90 % of project participants' BP readings by the end of week two of NUR 7803.
4. Analyzed all data with Intellectus statistical software and completed the project with practice recommendations by the end of week 6 on NUR 7803.

Diffusion of Innovation
The project action plan utilized the five stages of the change adoption process of the Diffusion of Innovation theory (Binji, 2020).

Knowledge
Patients were asked to take their blood pressure at home and report the readings to their providers. This information was instrumental for the provider to develop a care plan accurately (CDC, 2013;Guirguis-Blake et al., 2021;Murakami et al., 2015;Shimbo et al., 2020;Whelton et al., 2018).

Persuasion
Stakeholders were identified, and a meeting was held to discuss the clinic's advantages and disadvantages of SMBP monitoring. A PICOT question was created from the brainstorming done at the meeting.

Decision
An extensive literature search was done to find evidence to support the implementation of SMBP monitoring with interventions. A detailed, clinic-specific action plan was developed and discussed in a team meeting to ascertain feasibility.

Implementation
The project began when approval was received, and the participants were selected. Data will be collected for 8 weeks. Once retrieved, the data were analyzed for statistical significance.

Confirmation
The purpose of this project was to encourage patients to take accountability for their care while reducing their BP. Even without statistical significance, this process educated patients in managing a chronic disease, and it was a success.

Timeline
The SMBP project was developed, completed, and disseminated in approximately ten months. The first 15 weeks of the project entailed constructing a proposal by identifying the problem and translating the literature into beneficial practice recommendations. During the second 15 weeks, the proposal was sent for approval by the Institutional Review Board (IRB).
Once consent was given and the project participants were selected, the data was collected over 8 weeks. The last 15 weeks were used for analyzing the outcomes, survey results, and their relationship to the clinical significance. For a detailed project schedule, see Appendix G.

Budget
The project utilized the clinic staff to educate the intervention participants on using proper SMBP techniques and navigating the patient portal. The CPT code 99473 was used for this educational visit. CPT code 99474 was used for subsequent SMBP data review and interpretation, and CPT code 99423 was used for the monthly telehealth visit with the provider.
Minimal costs were incurred during the project. For a detailed explanation of the budget, see Table 1.

Results
The SMBP proposal was submitted to the EBP Project Review Council at USAHS for approval. The proposal was presented to the facility's IRB committee for approval. Once the approvals were obtained, the project participants were randomly selected from a list of hypertensive patients provided by the organization's Center for Clinical and Translational Science (CCTS). After thoroughly explaining the project's purpose, the project manager obtained signed consent for each participant. This consent reviewed why the participant was chosen, what was expected, and how they could quit at any time without repercussions. The consent also explained that there would be minimal risk or discomfort as they would only be taking their BP at home. The project participants' identities were protected by assigning the numeric digits as identifiers. Data stewardship and protection were always maintained by utilizing secured files on password-protected, locked computers and filing cabinets. All project data were kept for future projects on a password-protected computer.
The project manager collected BP data for analysis at the end of the 8-week project, see Table 2. The project manager analyzed the following three measures: 1. Difference in BP readings pre-and post-project 2. Percentage of participants who reported BP readings into the patient portal 3. Percentage of participants who attend the telehealth visit These measures captured the process and outcome of the project by analyzing the effectiveness of SMBP. The outcome of the BP readings pre-and post-project measured sustainability. The pilot group's telehealth visits at 1 month measured financial gains and the context of the participant's ability to utilize electronic technology, see Table 3. Fortunately, all participants completed the data collection with no missing data to address. The data were entered into Intellectus for analysis for statistical significance, but for most EBP projects, the clinical significance is the best way to measure effectiveness. Understanding the effectiveness of a treatment is essential to EBP.
A two-tailed paired samples t-test was conducted to examine whether the mean difference between Pre-project SBP and Post-project SBP significantly differed from zero (Intellectus, 2022). A Shapiro-Wilk test was conducted to determine whether the differences in Pre-project SBP and Post-project SBP could have been produced by a normal distribution (Razali & Wah, 2011). The results of the Shapiro-Wilk test were not significant based on an alpha value of .05, W = 0.94, p = .296. This result suggests the possibility that a normal distribution produced the differences in Pre-project SBP and Post-project SBP cannot be ruled out, indicating the normality assumption is met (Intellectus, 2022).
The result of the two-tailed paired samples t-test was significant based on an alpha value of .05, t(19) = 3.46, p = .003, indicating the null hypothesis can be rejected. This finding suggests the difference in the mean of Pre-project SBP and the mean of Post-project SBP was significantly different from zero (Intellectus, 2022). The mean of Pre-project SBP was significantly higher (143.60 mmHg) than the mean of Post-project SBP (130.50 mmHg), see Table 4. The benchmark of a decrease of 5 mmHg of SBP or greater by the end of 8 weeks was met.
The patient portal was utilized for reporting BP readings by 14 of the 20 participants (70%). The benchmark of 85% of patient portal reporting was not met. The six participants that did not use the patient portal stated they used their app to record the BP readings. Interestingly, only four participants (20%) attended a telehealth visit with the provider. The benchmark of 75% participation in a telehealth visit was not met. The main reason given by the participants who did not participate in the visit was that they did not feel it was necessary, as their BP was within normal limits.
After the data analysis, the outcomes were reported to the stakeholders. They were pleased that SMBP monitoring resulted in a significant reduction in the systolic blood pressure of most of the participants. Regardless of the statistical significance, the clinical significance was determined by the benefit of SMBP to all the patients' well-being. Even with a slight reduction in BP, patients have a lower risk of having a cardiac event (CDC, 2013;Murakami et al., 2015;Shimbo et al., 2020;Whelton et al., 2018).

Impact
The SMBP project was statistically significant, but more importantly, it was clinically significant because of the lowering of systolic blood pressure in participants at the end of data collection. The current practice of the patient monitoring their BP at home and keeping a written log of the readings has yet to be efficient for the patient or the provider. This may be due to several factors, such as the need for more training on taking their BP properly, the need for verifying the home BP machine for accuracy, and the inability to record the BP readings digitally. The SMBP project has successfully addressed the ongoing practice problem of patients monitoring their blood pressure and reporting the findings to their providers. The clinic's participants and providers were pleased with the reduction in SBP readings.
SMBP monitoring can rule out white-coat hypertension, which is often misdiagnosed (Johansson et al., 2021). Implementing the SMBP process on a larger scale may require purchasing loaner BP machines for patients to use short term. A curriculum for training staff and patients should be developed to ensure proper home BP monitoring techniques. While written literature would be sufficient, a hands-on demonstration for the patients would be ideal. During the face-to-face interaction, training on how to navigate the patient portal could be included.
Fortunately, there are CPT codes that can be billed for this instruction. A concerted effort should be made to enroll all patients into the patient portal and educate them on navigating it. BP data entered there will ensure an evaluation of the effectiveness of SMBP. The process will be sustained by implementing the SMBP protocol with all patients diagnosed with hypertension within the clinic. Further discussion has been initiated to implement the SMBP protocol in other ambulatory care clinics.
There were some limitations to this project. The initial goal was to recruit 30 participants for a robust sampling. The recruitment phase began a few weeks before Thanksgiving, and many potential participants decided against enrolling because of the upcoming holidays. Because of time constraints, the project started when 20 participants were obtained. Another area for improvement was the lack of interest in a telehealth visit with a provider in week 4 of the project.
This would have been a prime opportunity to educate on healthier lifestyle choices. It also could have been a chance to discuss the participant's complications with the patient portal. While some participants used their app to record their BP readings, using the patient portal is optimal. Data entered into the portal is seen by the provider and is annotated in the chart. This would ensure that the provider would know when the patient is in a hypertensive crisis. The project met the goal of lower blood pressure, as well as the added benefit of increasing patient engagement.

Dissemination Plan
Dissemination of the results of a change project is essential in making others aware of the impact and overall outcome (Harris et al., 2020). A peer review of the manuscript was done by DNP professors at USAHS and colleagues at the organization before publishing. A PowerPoint presentation was given at the conclusion of the project to the stakeholders. The Scholarship and Open Repository (SOAR) at USAHS published the manuscript to make the information readily available for researchers. Oral poster presentations were done at the organization's annual poster presentation and for the doctoral committee at USAHS.
Because the AHA has extensive research on SMBP, this professional society has been contacted to begin the submission process for publishing this manuscript. The organization has some professional cardiology journals that would be appropriate for publication. Specifically, this project will be submitted to the Blood Pressure Monitoring Journal. This journal maintains its ethics of scientific publishing as a member of the Committee on Publication Ethics. The peerreview committee comprises experts in the field who review the manuscript to ensure its originality and significance. Wolters Kluwer has an online submission and review system that assists authors in meeting the stringent guidelines for peer review and publication (Wolters Kluwer, 2022). Dissemination of the manuscript on a global level is the goal, as the success of this project may benefit other clinics that are managing hypertension.

Conclusion
This project aims to incorporate optimum healthcare strategies for those with hypertension. This chronic disease is insidious and can be deadly if not managed appropriately and consistently (Shimbo et al., 2020;Whelton et al., 2018). The literature shows that SMBP, with additional interventions, reduces BP in adults (Beran et al., 2018;CDC, 2020;Shimbo et al., 2020;Whelton et al., 2018). This change project implements an SMBP process that includes utilizing the patient portal to record the daily BP measurements and scheduled telehealth visits to discuss lifestyle modifications and medication adjustments. With increased knowledge of the importance of a proper diet, reduction of salt, exercise, and medication adherence in managing HTN, the patient can become more engaged in their health. By using SMBP monitoring daily, the patient is aware of their BP readings and can see when changes are necessary. Another benefit is the collaboration of care with the healthcare team using the technology available through the organization's EHR. The patient portal provides a platform to store data for the clinician to review in the patient's chart. These trends allow the provider to make decisions quickly on the plan of care changes. Together, the patient and the healthcare team create an  Note: All budget entries are estimates. Expenses are based on means. Revenue estimates do not include potential cost avoidance due to realized outcomes. All costs associated with salary and benefits, patient care supplies, and overhead are fixed indirect expenses unrelated to this project. Project costs are nominal for printing and laminating, under $100.    Asche, S., Dehmer, S., Bergdall, A., Green, B., Sperl-Hillen, J., Nyboer, R., Pawloski, P., Maciosek, M., Trower, N., & O'Connor, P. (2018). Long-term outcomes of the effects of home blood pressure telemonitoring and pharmacist management on blood pressure among adults with uncontrolled hypertension. JAMA Network Open, 1 (5) ii. Place feet flat on the floor and uncrossed.
iii. Rest an arm on a table at heart level.
iv. Place the cuff on the bare arm just above the elbow at heart level.
c. Proper technique i. Do not smoke, exercise, or drink caffeinated drinks or alcohol within 30 minutes of measurement.
ii. Do not talk, text, or use technical devices.
iii. Write down the reading if the machine does not store them automatically.
iv. Wait one minute and repeat the process.
v. Take two BP readings in the morning and two in the evening.
d. Use of a patient portal to record BP readings i. Ensure the patient has access to portal ii. Annotate BP readings in the patient portal.
iii. The clinician will be alerted in the patient portal if BP is out of range.