Team- and Patient-Based Care for Hypertension and Diabetes

Welcome to Heart to Heart Nurses, brought to you by the Preventive Cardiovascular Nurses Association. PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management.

Geralyn Warfield (host): I'd like to welcome our audience to today's episode where we're going to be speaking with Thomas Hinneh about a wide variety of topics. So, I'm going to let him introduce himself to you.

Thomas Hinneh (guest): Hello everyone. my name is Thomas Hinneh. I'm actually from Ghana. I'm a staff of the Ghana Health Service. I’m a professional nurse and a public health practitioner. I'm the Founder and Executive Director of HI Foundation Ghana, an NGO [non-governmental organization] creating awareness for hypertension and diabetes in community settings—specifically, rural communities.

I'm currently a student at the Johns Hopkins University, specifically the School of Nursing. [00:01:00] And I'm happy to be here today. Thank you.

Geralyn Warfield (host): We're so glad to have you as a guest on our podcast. And let's start off talking about team-based care. I think that's a word that, or a phrase that, we use across the globe, and it might be a little bit different depending upon where you are, if you've got a staff that's small, a staff that's large.

So, how can we address CVD prevention using team-based care, and making sure that we are appropriately treating our patients?

Thomas Hinneh (guest): Thank you very much for this question. Before I begin, let me be quick to say that, in the last 10 years, the burden of CVD, particularly in low-middle income countries, including Ghana, has grown significantly.

And when you look at the number of physicians we have, especially in Ghana, we'll never be able to meet the needs of our patients without working together as a team. And so, team-based care, as WHO [World Health Organization] has [00:02:00] recommended for low-middle income countries, is an approach where you have two or more healthcare providers coming together to provide a patient-centered, you know, care as far as hypertension, management is concerned.

Geralyn Warfield (host): And team-based care can be used for a lot of other disease states as well. So, hypertension is the one on which we're going to focus today. But I'd like our listeners to kind of think about the other disease states that they may be managing as well and how that might be applicable there as well.

So, what are the special considerations when you have a small team of two people that are doing that team-based care, would you, what are some key qualities that you think that make that effective?

Thomas Hinneh (guest): Great. Thank you. So, when I talk about team-based care, I always love to reflect on my previous experiences, working in some district hospitals in Ghana. And I believe that one of the most important elements of an effective team-based care is the clarity of roles. When people come on board to work together, there should be a [00:03:00] distinction as to the specific roles that they'll play in the team.

And so, working together with medical doctors, nutritionists, pharmacists, and all kind of healthcare workers, one thing that stood out was that everybody came on board with specific responsibilities.

So, on a usual day, I would actually coordinate the clinic activities, but I had nutritional officers coming in to give nutritional support in terms of counseling, health education with patients. I had the nurses coming in to check the blood pressure of patients, almost everyone. And then, I will facilitate, you know, the counseling sessions and the health education and the focus group discussions.

And after those sessions I'll switch to the consulting room to do some prescriptions. And sometimes you have the pharmacist also come in to, you know, lead some interventions that will help in medication adherence. So, one of the [00:04:00] important elements is to have every member on the team having a specific role to play.

Another element I would want to talk about is leadership, more of a collective leadership. And when I talk about collective leadership, every member of the team should be able to, you know, live with the understanding that they own the clinic. And so, we are able to leverage an individual’s competencies. And you know, the clinic doesn't center around one person, but we all come together as a team. With the thinking that the clinic is for us and for the patients.

So, collective leadership, clarity of rules, these are two outstanding elements for a successful team-based care approach to hypertension management.

Geralyn Warfield (host): I really appreciate those great perspectives on what it takes to actually get patient outcomes improving, working together as part of a team, no matter the size of that team. That's wonderful.

And one of the things that happens on a team is sometimes we have new to career individuals, students perhaps, or early [00:05:00] career nurses or other providers. And I'm wondering about your perspectives about providing mentoring for those individuals and how that plays into your daily clinical life and the outcome of our patients.

Thomas Hinneh (guest): Thank you for this question, and I must be quick to say that I have benefited significantly from, you know, a lot of, senior officers of the Ghana Health Service that I've worked with in the past.

And I remember when I started my, you know, the journey of, you know, being a nurse—in somewhere 2015—I had the privilege to work with a district director who is retired now, who gave me the opportunity to, as it were, express what I'm thinking, all the ideas I had in mind. And that was when I actually conceptualized the idea of team-based care far before 2018, when the idea of team-based care approach to management, hypertension [00:06:00] became more popular.

They give me the platform to showcase all the skills I have. And I believe that, for students and early, you know, career researchers, those who want to go more into CVD, you need to tap into the experience of those who have gone ahead of us. Usually, they know more than we know. We should not allow, you know, sometimes I call it youthful exuberance and over-commitment to make change, to lead you.

Sometimes people who have experienced things that we have not, and it is good to allow them to, you know, as it were, guide you.

But I must also say that, in terms of my research journey, I had opportunity to meet a lot of people like my current advisor, Professor Yvonne Commodore Mensah, who is doing almost the same thing that I have, you know, been doing in the past, seven years. And she has actually shown me, you know, potential career trajectories [00:07:00] that could, you know, build on all the experiences and all the things I've done. And she continues to link me to all the potential networks that are significant to my career improvement.

And so, I believe that yes, we have intrinsic motivation, we have intrinsic passion to succeed, to improve life, to make changes. But when we link, when we network with the relevant people, they are able to guide us. They serve us some sort of accountability by certain timelines for achievement of goals and so on and so forth.

So, there is this saying that if you want to go far, don't go alone. Go with people. And I believe that mentorship is the best approach to achieving a lot as far as cardiovascular research is concerned.

Geralyn Warfield (host): Thank you so much. We're going to take a quick break and we will be right back.

Geralyn Warfield (host): And we're back. And we're going to shift gears just a little bit and talk about patient-centered care. Thomas, what, what are your thoughts on that?

Thomas Hinneh (guest): Thank you very much for this question. I believe that the, the [00:08:00] central goal of team-based care approach to management of hypertension is patient-centeredness. Hypertension is a chronic condition, and so it requires an ongoing management as well as lifestyle modification.

But the, the point is that when we talk about lifetime modification, we expect it from the patient. It is the patient who is at the center of all the interventions that we design. And so, to be able to achieve an optimal blood pressure control, which is the goal of the healthcare interventions we deliver around hypertension care, we need to have the patient at the center.

And when I say we need to have the patient at the center, we need to put measures in place that would encourage them to voice out their consents. I often tell people it is not easy to live on daily medications, and so when somebody's going through that phase of life, you need to be able to have them speak up, put in mechanisms that will [00:09:00] enable them to let them tell you how they feel and what will work for them. And so patient-centeredness is the only way we can get patients [to] speak up and engage with them meaningfully.

Another important point about patient-centeredness is the fact that, it leads to patient satisfaction. And I say this with some of the experiences I've had in the past that. Any time I engage with my patients in the consulting room, you know, so meaningfully that be able to speak openly as if they are in their houses and so on and so forth. They leave the consulting rooms very satisfied. And so, when you meet them outside and say, “How was your experience today?”

“Oh, today was very nice.” The only reason why it is nice was because they had engaged with somebody in the consulting room very meaningfully. So, to be able to, you know, achieve the goal, achieve the purpose for which we use team-based care, we need to engage the patients appropriately. Let them have a say in the [00:10:00] interventions we deliver.

And I always say, a satisfied patient is the most engaged patient.

Geralyn Warfield (host): Wonderful thoughts. And so, let's think about our patients with hypertension specifically. And obviously, we want patient-centered engagement. We want patient, patient-centeredness as you've described it. But how do we help our patients understand the links between their hypertension, diabetes, and also cardiovascular disease?

Thomas Hinneh (guest): Thank you very much. And I must be quick to say that most of the patients that I've nursed so far had both hypertension and diabetes. And so, the first point is to create some sort of awareness. You would think that anyone who has diabetes, anyone who has hypertension knows that they are at risk of developing either, but that is not really the case.

Most of them are unaware, so the first step is to raise their awareness. Let them know: once you have hypertension, there is a risk [00:11:00] of also developing diabetes and vice versa. And I remember when we went for some visits in Ghana with my advisor, Professor Yvonne Commodore Mensah. One of the recommendations that we had from some of the key stakeholders was to deeply investigate the relationship between developing diabetes and hypertension.

And I always say that, if somebody lives with hypertension, it is quite a lot. It takes a lot to overcome, but when they have the two, then the responsibility is double. And so, the first step after creating awareness is to let them know the risk factors that leads into developing the other.

So, once they now know, “Okay, so I have diabetes, I'm at a risk of developing hypertension, okay, some of the other complications that I'm likely to develop are so, so, and so,” then it helps them. It gives them some sort of awareness that [00:12:00] they live with, you know, and that goes into informing all the healthcare decisions, or all the nutritional choices, and all the other, you know, decisions you can think of. So, the first step is let them be aware of it, and guide them on how to, you know, prevent themselves from developing it.

But I also touch on the health system perspective. Apart from letting the patients know, healthcare providers must also know that our patients are at risk of developing comorbidities. And so, efforts like cardiovascular risk assessment, which is often not done in Africa, we should aim at, you know, prioritizing some of those interventions.

And there is actually a study in Ghana where nurses were actually involved in cardiovascular risk assessment and the end result was improved, you know, blood pressure control and you know, others. So, I think it is really relevant that, moving forward, we pay a bit of attention [00:13:00] into, you know, managing, hypertension, diabetes, comorbidity.

And I must emphasize that the projects we currently have ongoing in Ghana, which is funded by PSF, actually brought to light the number of patients who have both hypertension and diabetes. And we are hoping that the data will help us to, you know, come up with some interventions to see how we can predict their risk of CVD events, which will inadvertently contribute to designing interventions that will protect them from, you know, developing such events.

Geralyn Warfield (host): And the last question I have for you is about the motivation and inspiration that healthcare professionals have, or maybe need more of, for preventing cardiovascular disease and for managing it. How do you find motivation? Everybody is very busy anymore. It doesn't seem like there's enough hours in the day for everything.

So how do you nurture that?

Thomas Hinneh (guest): That is a great question, and it's actually something [00:14:00] I've never, you know, said anyway. I think that, as early as, seven years, I lived with a grandmother who, you know, had both hypertension and diabetes. And I witnessed firsthand how stressful it is to live with the two.

Those were the days that people stigmatized living with diabetes. Those were the days that you leave home at 6:00 AM to go for clinical appointment and get back home at 6:00 PM. And so I imagined how stressful life was. And anytime I had conversations with her, I could feel the pain.

But at that time, I had one thing on mind. You know, how can we make health services more accessible? How can we put things in [00:15:00] place so that people living with, you know, hypertension, diabetes, or both, can live a meaningful life? And I regret to say that the most popular recommendations at the time was to live on one finger of plantain a day.

And so anytime people leave home, you know, she was alone, she would say, “Hey guys, come. Come and help me.” We'll help her prepare like, you know, what she loves to eat. But, sadly, the next day her blood sugar will shoot up and you know, that was the first time I've seen people, you know, experience seizures because of high blood sugar. It was bad.

So right from day one, I think I knew what I wanted to do. And so, when I started my professional journey as a nurse in a district hospital in Ghana, and I was in the consulting room and I saw people coming, just getting their medications and going, I felt like no, [00:16:00] there could be more to this.

And so, I started something like a focus group discussion with just five patients. The next week, the number increased to about 12 until the number shot up to 200. Because the patient felt I was providing services that met their needs.

And so, I'm always inspired by the experiences that my grandmother went through, and I'm committed to going further.

And so sometimes, even though there are challenges, it's not easy. Resources are inadequate. Health systems itselves are something else, but I feel like, when I imagine the challenges, you know, she went through, I feel people should not go through the same. And I try as much as possible to do whatever I can within my capacity to, you know, come up with some interventions that will improve hypertension and diabetes care.

And that has led me to doing a lot of things, including some projects that I'm currently involved with PSF Germany. And we've been able to [00:17:00] train over 120 healthcare providers. We've supported them with some equipment, and we are looking forward, hopefully next month, to help them provide services such as free A1C test for all patients with diabetes.

So, this is where I get my motivation from. And I think I got it quite early and that is able to help me overcome any challenge I come across along the way.

Geralyn Warfield (host): Such an inspirational story and seeing our patients as people first and the challenges that they face help us all be better providers each and every day.

No matter what our care setting is, no matter what our job title is, no matter where in the globe we're doing our work—it all does make a difference every single day.

Thomas Hinneh (guest): Thank you very much. And I really buy into that. So usually when I talk about patient-centeredness, I do so with personal, you know, passion. Personal commitment, you know.

Patients come to [00:18:00] us understanding the power hierarchy within the healthcare systems. And I think this is something every healthcare provider must know. And sometimes when I engage with my colleague professionals and they tell you, “So today, I, I went to the hospital, not in uniform, as a regular patient,” they actually feel how our patients also feel when they approach health systems.

So, when patients come to us, It is such a privilege for us to attend to them. And we should make sure we are engaging them meaningfully, treating them with dignity and respect and incorporating their needs into whatever intervention we, you know, come up, with if they goal is to improve upon their health.

Geralyn Warfield (host): It has been a delight today to speak with Thomas Hinneh about patient-centered care. I hope you have been as [00:19:00] inspired as I am, to go forth and do good work.

This is Geralyn Warfield, your host, and we will see you next time.

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