Abstract
This case study explores the role that pharmacists can have managing resistant hypertension (RH) in rural Appalachian veterans, where health care access is limited. RH, defined as blood pressure above target despite adherence to multiple antihypertensive medications, presents challenges in chronic disease management. The Department of Veterans Affairs (VA) has integrated CPPs to improve medication adherence, reduce hospitalizations, and enhance blood pressure control, particularly in underserved areas. The patient, a 65-year-old male veteran with hypertension, obstructive sleep apnea, depression, and PTSD, had struggled with poorly controlled hypertension for years, experiencing adverse reactions to multiple antihypertensive medications. Living more than 60 minutes from the nearest VA facility, he had not seen his primary care provider since early 2021, exacerbating his condition. Despite initial reluctance to restart medications, the CPP implemented a stepwise management approach, utilizing telehealth for remote blood pressure monitoring and regular follow-ups. Over several months, pharmacologic therapy combined with lifestyle modifications led to significant blood pressure improvement. This case highlights the crucial role of CPPs in rural health care, offering accessible, continuous care and personalized management of complex conditions. Telehealth and remote monitoring further facilitated care, overcoming geographic barriers and enhancing patient engagement. The collaboration between pharmacists and specialists ensured comprehensive care and optimized treatment. This case demonstrates the potential for expanding CPP roles in rural areas to improve chronic disease management, reduce health care disparities, and enhance patient outcomes through telehealth and team-based care.
Keywords
Background
Hypertension is a major risk factor for cardiovascular disease, and resistant hypertension (RH), defined as blood pressure above target despite adherence to three antihypertensive medications (including a diuretic), is particularly difficult to manage. This condition requires a comprehensive approach to identify secondary causes, optimize therapy, and address the patient’s underlying health issues.
Uncontrolled hypertension enhances the risk for development of adverse renal and cardiovascular outcomes. The presence of hypertension increases the risk for development of heart failure, ischemic stroke, ischemic heart disease, and chronic kidney disease. Hypertension is one of the most prevalent, modifiable risk factors for premature cardiovascular disease.
The Department of Veterans Affairs (VA) has been a leader in recognizing the value of Clinical Pharmacist Practitioners (CPPs) as part of the health care team. CPPs are advanced practice pharmacists who play a key role in optimizing medication therapy, managing chronic conditions, and collaborating with health care teams to improve patient outcomes, particularly in underserved and rural areas. Pharmacists have long been involved in the management of chronic conditions, but their role has been expanding, especially in rural and underserved areas. Previous studies have demonstrated that pharmacist-led interventions improve medication adherence, reduce hospitalizations, and enhance blood pressure control. However, these studies have often been conducted in more urban settings, where health care access is not as limited. This case report builds upon prior research by focusing on the integration of CPPs in rural health care and utilization of telehealth as a means to overcome the challenges of geographic isolation and health care disparities. Telehealth is the use of digital information and communication technologies that allows individuals to access health care services remotely.
In regions like rural Appalachia, health care access is particularly strained, with limited options for specialists, extended travel times to health care facilities, and a high burden of chronic disease. Factors like socioeconomic status, health literacy, and geographic isolation exacerbate these issues. In response to these barriers, CPPs can provide a critical bridge in chronic disease management, improving both accessibility and continuity of care for rural patients. This case study highlights the value of pharmacist-driven interventions in the management of resistant hypertension for a veteran who lives 78 miles (roughly 90 minutes) from the nearest VA facility, illustrating the potential for CPPs to reduce health care disparities in rural areas.
Case Presentation
A 65-year-old male veteran with a complex medical history, relevant for obstructive sleep apnea, depression, post-traumatic stress disorder (PTSD), tobacco use and hypertension, was referred to the VA cardiology department for management of his hypertension from his mental health provider. Hypertension was first diagnosed in 2018 (Stage 2). The patient resided in a rural community in Appalachia, approximately 78 miles from the closest VA health care facility, and had not seen his primary care provider, or other providers aside form mental health since early 2021, due to the COVID-19 Pandemic. The veteran had been struggling with poorly controlled hypertension for several years, having failed multiple medication regimens due to adverse effects. Prior treatments included amlodipine (bilateral edema-2018), metoprolol tartrate (dizziness, falls, fatigue-2018), chlorthalidone (fatigue, sexual disfunction- 2019), and hydrochlorothiazide (fatigue, general malaise-2020), all of which were discontinued due to adverse drug reactions. Adverse effects were reported by the patient during routine mental health and nursing evaluations and confirmed by chart review.
Additionally, the patient had a resistance to medications and health care providers, which presented another challenge in managing his condition. At the time of referral to the Clinical Pharmacist Practitioner (CPP) in January 2024, the patient was not on any antihypertensive therapy, and his blood pressure had reached dangerously high levels (208/146 mmHg, heart rate 92 bpm). The veteran was unwilling to restart medications at our initial visit, but agreed to begin self-monitoring blood pressure and agreed to weekly telephone and video follow-up visits with the CPP.
Over the course of 6 months, the CPP implemented a stepwise approach to managing this veteran’s hypertension, combining pharmacologic therapy with lifestyle modifications, while closely monitoring progress through home telehealth remote monitoring and follow-up visits. Total of 15 video and telephone encounters, all of which were conducted solely by the CPP occurred during this time period (Figure 1). The CPP also facilitated consultations with specialists, including cardiology and nephrology, to rule out secondary causes of hypertension and optimize treatment. Despite the patient’s initial reluctance to engage in pharmacotherapy, close follow-up and the availability of self-monitoring blood pressure monitoring via the VA’s Home Telehealth program allowed for gradual improvement in his blood pressure control. The Home Telehealth Program used by the VA allows patients to report vitals from home, unlike many private insurers which may require patients to visit a clinic for video visits. Additionally, pharmacists in the VA can initiate and modify therapy without physician countersignature under scope of practice, which is not always the case in the private sector. Timeline of the stepwise approach taken for management of this complex patient.
Discussion
This case highlights the critical role that Clinical Pharmacist Practitioners (CPPs) can have in managing complex, resistant hypertension, especially in underserved, rural populations. The integration of pharmacists into the health care team in these areas offers a unique and impactful solution to addressing these barriers. Pharmacists have long been recognized as highly accessible health care professionals, often being the first point of contact for individuals seeking medical advice or assistance. In rural settings, where health care providers are sparse, this accessibility becomes especially valuable. The integration of pharmacists into health care teams allows for more personalized, patient-centered care, which is critical for managing chronic conditions like hypertension.
Additionally, the close follow-up made possible by the pharmacist’s involvement provided a level of continuity and attention that would otherwise be difficult to achieve in a rural setting. This patient received weekly check-ins, which allowed for the timely monitoring of blood pressure readings, the identification of side effects, and adjustments to therapy as needed. Regular follow-up is particularly important in the management of resistant hypertension, as it often requires the fine-tuning of treatment regimens and frequent reassessments to ensure that blood pressure control is optimized. The availability of a pharmacist for frequent follow-ups ensured that the patient received individualized and patient-centered support.
Furthermore, telehealth and remote patient monitoring—tools that were utilized in this case to allow the patient to self-monitor blood pressure—are increasingly important in rural health care. By utilizing home-monitoring devices and telehealth technology, pharmacists can monitor patients remotely, provide timely interventions, and reduce the need for frequent in-person visits. This type of care is particularly beneficial in rural areas, where the cost and time required for patients to travel to health care facilities may discourage them from seeking care regularly. Unlike private insurance systems that may mandate patients be at a health care facility for telehealth consultations, the VA allows remote consultations for eligible veterans, expanding access and convenience.
Finally, the collaboration between pharmacists and specialists (in this case, cardiologists and nephrologists) was also crucial. Pharmacists can serve as vital liaisons between the primary care team and specialists, ensuring that care plans are integrated and that patients receive comprehensive evaluations. Treatments, and smooth transitions of care. The patient attended both cardiology and nephrology appointments. The cardiology workup focused on ruling out ischemic heart disease and arrhythmias, while nephrology assessed potential secondary causes for resistant hypertension, including renal vascular disease.
Given the positive outcomes demonstrated in this case, there is substantial potential for expanding the role of pharmacists in rural health care. One potential avenue for growth is the increased use of telehealth platforms that allow pharmacists to provide virtual consultations, monitor home health devices, and manage chronic conditions remotely. This approach can help reduce the need for in-person visits, thus overcoming one of the major barriers to health care access in rural areas—long travel distances.
Conclusion
This case underscores the critical role of Clinical Pharmacist Practitioners (CPPs) in managing resistant hypertension, particularly in underserved rural populations. The ability to provide continuous care, offer personalized medication management, and collaborate with specialists has the potential to significantly improve patient outcomes in these areas. Pharmacist-driven care in rural communities not only enhances accessibility to care but also optimizes chronic disease management, reduces burden on primary care providers, and improves the overall quality of life for patients. Expanding the role of pharmacists in rural health care settings—especially through telehealth and team-based care models—could be a key strategy in addressing health care disparities in these regions.1-3
Footnotes
Acknowledgement
The authors would like to express their sincere gratitude to the colleagues and staff who provided valuable insights and support throughout the preparation of this manuscript. Special thanks extended to the editors for their constructive feedback and those who assisted with proofreading prior to submission. We would also like to extend our deepest appreciation to the veteran in this case report, as their willingness to participate made this work possible.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Privacy and HIPAA Compliance Statement
This case report adheres to all relevant privacy and confidentiality laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). All patient information presented in this case is de-identified to ensure patient confidentiality. No personally identifiable information (PII) or Protected Health Information (PHI) has been disclosed in this submission. Case was reviewed and approved by Department of Veterans Affairs Privacy Office.
