To use practice facilitation (PF) + community health worker (CHW) facilitation as a practical and sustainable implementation strategy to support the implementation and evaluation of three multi-level evidence-based interventions [nurse case management (NCM), remote blood pressure monitoring (RBPM), and social determinants of health (SDOH) support] delivered as an integrated community-clinic linkage model [Practice support And Community Engagement (PACE) to address patient-, physician-, health system-, and community-level barriers to hypertension (HTN) control in Blacks across 25 primary practices within NYU Langone Health in New York City (NYC) and, in partnership with an established Community-Clinic-Academic Advisory Board and HealthFirst (NYC's largest Medicaid payer).

The goal for the UH3 Implementation Phase (Years 4-7, Intervention) is to evaluate a stepped-wedge cluster RCT of 25 primary care practices in Black patients with uncontrolled hypertension (HTN)](streamdown:incomplete-link)

UH3 IMPLEMENTATION PHASE (Years 4 - 7): INTERVENTION

Inclusion Criteria:

Patients are eligible if he/she:

1. identifies as Black (through EHR code or self-report)
2. is 18+ years of age
3. has a diagnosis of HTN (identified by ICD-10 codes for HTN)
4. prescribed an antihypertensive medication(s)
5. has a clinic BP > 130/80 mmHg

Exclusion Criteria:

Patients will be ineligible for the study if they:

1. are deemed unable to comply with the study protocol (either self-selected or by indicating during screening that s/he could not complete all requested tasks)
2. participate in other hypertension-related clinical trials
3. have significant psychiatric comorbidity or reports of substance abuse (as documented in the EHR)
4. plan to discontinue care at the site within the next 12 months; or
5. are pregnant or planning to become pregnant in the next 12 months

IMPLEMENTATION EVALUATION

1. NYULH Primary care provider (MD/DO, NP), Clinical Director, Site Administrator, Medical Assistant, or administrative staff employed at the participating practices and interacts with at least five patients with a diagnosis of hypertension; or
2. NYULH Nurse case manager within centralized service; or
3. Staff and leadership of community- and faith-based organizations serving the Black community; or
4. NYULH Organizational leadership; or
5. NYULH Project Staff: Community Health Workers/CHW Supervisor/Practice Facilitators; and
6. Able and willing to provide consent

Exclusion Criteria:

1. Refusal to participate

Individual participant data that underlie the results reported in this article, after deidentification (text, tables, figures, and appendices) will be shared upon reasonable request.

Beginning 9 months and ending 36 months following article publication or as required by a condition of awards and agreements supporting the research.

The investigator who proposed to use the data will have access to data upon reasonable request. Requests should be directed to Jennifer.zanowiak@nyulangone.org. To gain access, data requestors will need to sign a data access agreement.