Turning to the Community: New York City Leverages Church Ties for Population Health

When the lay health worker logs into the NexJ HealthTracker, they have three different operative tabs across the top. One says ‘participants,’ and when you click on that, you see listed across a line, all the people in the church who have signed up and have shared their blood pressure, weight, or steps walked. So this is basically like a digital file box. It’s really not that different from flipping through a file box, except that when you click on ‘blood pressure,’ it brings up to the top the people with the highest blood pressures. You could do the same thing with an Excel spreadsheet, but it wouldn’t be as manipulable.

Now, these lay health workers had previously had training with what’s called “Keep On Track.” And we advise them that when someone has a blood pressure taken and it’s above a threshold that we regard as dangerous, something like 190 over 100—averaged across two readings—our advice is that that person should seek medical advice that day. If it’s above 140 over 90, or borderline, our counsel is that that person should have a regular doctor, take their medications as prescribed. The volunteers don’t get into the question of what the medication is, even though many of them are nurses; instead, they focus on referral and counseling.  As we move forward with this program, what we’d like to do is to develop a protocol where the intervention is not just counseling, but very specific referrals to programs.

Do you have any metrics yet on the number of blood pressure readings that are on these laptops so far?

Four churches had completed their trainings in March, and by the end of April, 72 people at the four churches had signed up, and I expect the number to reach 100 by the end of May. Signing up means you sign up for the Dossia Personal Health Record and click the permission to enable the NexJ app.

Is the information being kept by the health ministries? Or are some people actually going to maintain their own PHRs?

We don’t know yet exactly how that will shake out; it’s one of the things we’ll learn by the end of this phase of the pilot in July, as we do some listening sessions and user discussions. But we very purposely purchased the technology with a clear signal that it should work both for someone who was computer-literate and wanted to use a computer and also for someone who was not.

This clearly should be replicable elsewhere, right?

Yes. If anything, the institutionalization of programs in faith-based organizations is moving forward. For example, the city of Memphis has a very strong relationship with Methodist Hospital down there. And so there are many organizations, including parish nursing organizations, that could take this up, if it would prove to be usable and valuable.

And let’s say, OK, I’m going to my church and am having my blood pressure taken, and it’s uncontrolled, and how does that relate to my doctor? I was determined that we not approach this as a health information exchange puzzle, because my feeling was that we wouldn’t really progress very far in the short term. So right now, we’ve given the churches printers, so they’re able over the next month to start printing out cards with the blood pressure charts on them that people can take into their doctors’, so the doctors can look at the blood pressure readings. And into the future, obviously, if the doctors want to see these readings in some automated, standards-based exchange, we could do that. That’s sort of the main thing that Dossia does; so it’s doable; we’re just waiting for a use case to emerge.