Recently, LA Health Services (DHS) was honored with L.A. Care’s first Provider Equity Award. This award recognizes DHS’s efforts to improve health outcomes for patients with diabetes and those with uncontrolled high blood pressure (BP), through the Food Rx Program and the Remote Nursing Hypertension Optimization Management & Engagement Program (RN HOME). This award highlights the incredible heart and mission of DHS and the commitment of teams to serve the community in innovative ways to meet complex needs. Here is a video about the award.

The COVID-19 pandemic highlighted the needs of our communities and what they were experiencing, including food insecurity, uncontrolled BP’s, as well as the digital divide. Proactive engagement and outreach were key to understanding the needs of the communities we serve. Listening to our communities directly was crucial in helping to identify opportunities to address those needs. Disparities are complex, are not one-size-fits-all and require appropriate resourcing. The absence of health equity manifests and is evidenced by poorer health outcomes and overall well-being of those that do not have the same accessibility to services. Health equity is intended to ensure access to services in a way that serves the person best. It requires awareness, education, cultural and linguistic considerations and resources. Health equity is important because everyone deserves to be healthy and to be well.

As screening efforts continued, DHS workforce members were able to partner with different sites to address these needs and provide tangible resources, including local food distributions at clinics and distribution of BP monitors to patients with uncontrolled hypertension. While the pandemic created challenges related to space, needed protocols and staffing resources, these workforce member teams persevered and kept this work as a priority. The pandemic highlighted the need for continued screening and proactive efforts to address the increased prevalence of food insecurity. The partnerships between DHS, the Department of Public Health (DPH) and community-based food organizations, became stronger and DHS was able to conduct food distributions at many of our clinic sites. In total, with the DHS-DPH Food Rx Collaborative, 10,322 households were served, and 241,314 pounds of produce were distributed. The Food Rx Collaborative is a shared learning space and is planning for expansion beyond food distribution efforts. These efforts have been extremely valuable to the communities served and highlight the importance and connection between access to healthy foods and overall health, as well as authentic partnerships with other County Departments and community-based organizations.

Started in 2019, the RN HOME program aimed to help patients with uncontrolled high blood pressure reach their target BP. Through this program, providers refer patients who meet specific criteria and would potentially benefit from this program to the antihypertensive medication titration Nurse-Directed Clinic (HTN NDC). Designated HTN NDC Registered Nurses (RN) receive these referrals, then reach out to the patients to begin working with them. These specially trained RNs work closely with the patients, utilizing Standardized Procedures to work at the top of their license, manage their patients’ uncontrolled hypertension through medication titration and education, and help their patients reach their target BP. These RNs actively facilitate patient-centric use of telehealth technology that meets the patients where they are, rather than offer a “one-size-fits-all approach” to improve the management of uncontrolled hypertension. HTN NDC visits were offered and conducted as in-person, telephone or video visits, depending on the patients’ needs, preferences and capabilities. During the initial visit, patients would receive a BP monitor, BP monitoring log, and education on hypertension, importance of medication adherence and monitoring BPs. Once patients reach their target BP, they graduate from the program. Through the RN HOME program, patients have been able to reach their target BP goal in an average 1.6 visits. Currently, HTN NDC’s have been implemented at Mid-Valley Comprehensive Health Center, San Fernando Health Center, El Monte Comprehensive Health Center, High Desert Regional Health Center, Harbor-UCLA Medical Center, Lomita Family Medical Clinic and Rancho Los Amigos National Rehabilitation Center. Thank you and congratulations to the HTN NDC RNs and leadership at each of these sites and to the HTN NDC training team for their hard work, efforts and continued commitment to this work and to our patients.

It is important to highlight and recognize the teams doing this incredible work. They too, have personal and professional challenges as a result of the pandemic, yet continue to show up and serve others. That is commendable and should be celebrated. It helps to increase morale and give hope for the sustainability of the work. Also focusing on the “why” and the vision and mission of the work we do helps to provide the foundation regardless of circumstances. Finally, identifying partners that can support and collaborate so that the organization does not feel isolated in the efforts is important. For all these reasons, DHS was recognized and honored with this first L.A. Care provider equity award – extraordinary work from these amazing teams serving our communities!