May 30, 2025
Did you know that chronic diseases are responsible for nearly 90% of health care costs in the U.S.? Conditions like heart disease, cancer, diabetes, obesity, and high blood pressure, also known as hypertension, are more than just headlines. As the leading causes of death and disability, they affect millions of lives daily and place a significant strain on the health care system.
Approximately 46% of OCHIN network patients are living with at least one chronic condition. Among the more than 7.4 million patients in the OCHIN network, nearly 16%—or almost 1.2 million people—are managing high blood pressure. Over 57% use Medicare, and over 41% of these patients live in rural areas, where access to health care can be limited.
That’s why OCHIN is committed to empowering communities nationwide to ensure access to quality care for their residents. By providing our network members with advanced solutions, tools and technology, we ensure that patients with high blood pressure receive the care they need, no matter where they live.
Ensuring rural access to quality care
Studies have found that people in rural areas are at higher risk for certain health issues. Rural areas tend to have a larger percentage of older adults, and a recent OCHIN analysis revealed that over 53% of patients with high blood pressure are over age 65.
In addition, rural residents with hypertension often face unique challenges and barriers that limit their ability to get the care they need, including long distances, provider shortages, and transportation issues.
OCHIN network providers help reduce these barriers by improving access to high-quality, affordable, community-based care. They are often a lifeline for Medicaid and lower-income patients, older adults, and rural communities, offering primary care and other critical health care services to residents, regardless of their ability to pay.
OCHIN research and data insights help our network members drive innovation and improvement at the intersection of rural health and chronic disease and deliver leading outcomes in hypertension care.
Advancing understanding of hypertension care through research
OCHIN’s research portfolio includes innovative projects that are transforming chronic disease management and advancing our understanding of hypertension care in rural communities. Among these are studies to:
- Reduce the impact of extreme heat and poor air quality on hypertension and asthma through evidence and interventions.
- Examine patterns of multiple chronic conditions among middle-aged and older adults using electronic health record (EHR) data, focusing on drivers of health like geography and other non-medical risk factors.
Other OCHIN studies aimed at improving our understanding of hypertension care focus on:
- Managing chronic diseases in community clinics and testing informatics tools to address barriers. Findings show that EHR alerts to screen and code for drivers of health are useful.
- Developing advanced machine and deep learning models for cardiovascular risk prediction and improving preventive medicine for low-income
- Evaluating remote patient monitoring devices for hypertension and diabetes management. Findings suggest that substantial resources are needed for effective use and patient education.
- Training community health workers to reduce the impact of drivers of health on chronic disease management and creating a national resource for studying hypertension and diabetes management in community clinics.
- Assessing telemedicine’s effectiveness in reducing treatment disparities for Latinos with hypertension and diabetes, and evaluating telemedicine use and its connection to recommended care services.
These projects collectively aim to improve chronic disease management and health outcomes in rural and other underserved communities.
Providing tools and best practices to drive better patient outcomes
For 25 years, OCHIN has provided integrated knowledge solutions to help our members achieve better patient outcomes in whole-person care. Being part of the OCHIN network allows members to customize their EHR systems to meet the specific needs of their communities, achieving clinical and operational excellence through OCHIN Epic.
OCHIN Epic tools and partner applications, such as MyChart, Care Message, and Artera, are essential for patient communication and engagement. These tools help patients and providers work together to manage high blood pressure effectively through regular blood pressure monitoring and checkups.
We also offer consultative support. For example, our practice coaches provided tailored assistance to five members implementing the American Medical Association’s (AMA) Measure-Act-Partner (MAP) framework. This framework uses evidence-based strategies, practice facilitation, and tailored performance metrics to improve hypertension management. Today, OCHIN continues to enhance metric documentation and integrate home monitoring devices within OCHIN Epic.
In partnership with organizations like the Centers for Disease Control and Prevention and the National Association of Community Health Centers, OCHIN tests tailored solutions to improve EHR systems for hypertension care in rural and urban community care settings. For example, from 2019 to 2024, as part of the Million Hearts Initiative, OCHIN’s comprehensive support helped two members develop tailored solutions to better support African American patients with uncontrolled high blood pressure. The City of Cincinnati Health Department expanded their care team with a clinical pharmacy approach, while Mercy Care implemented a self-measured blood pressure model to enhance clinical information sharing through MyChart.
Learn more
Access to quality health care is crucial, especially in rural communities where barriers can limit care. OCHIN’s members play a vital role in bridging these gaps, providing essential services to underserved populations. By leveraging advanced tools, technology, and comprehensive support, we empower our network to deliver leading outcomes in hypertension care.
OCHIN invites you to engage with our initiatives and resources to further improve health outcomes in your community. Explore our integrated knowledge solutions, including research, clinical support, and partner applications, to see how OCHIN can help you achieve excellence in hypertension management.
