Nearly half of U.S. adults have high blood pressure, and about one in four of them has it under control, according to the Centers for Disease Control and Prevention (CDC). For a practice, raising blood pressure control rates across a patient panel is less about any single patient and more about the system around them: how pressure is measured, how treatment is standardized, who follows up, and what data the team reviews.
This article lays out six steps drawn from CDC and Million Hearts resources, the 2025 American Heart Association (AHA) and American College of Cardiology (ACC) guideline, and published quality improvement work. It also explains which blood pressure number counts as controlled, because the answer changes by guideline and by quality measure.
The short answer The six steps are: know your panel and your measure, measure blood pressure accurately every time, standardize treatment with a protocol and team based care, add home blood pressure monitoring with clinical support, remove barriers to taking medicine and getting care, and review data on a set schedule. No single step is likely to move the rate on its own. |
Where Blood Pressure Control Rates Stand
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Source: CDC, High Blood Pressure Facts, updated June 2, 2026. CDC defines high blood pressure as 130/80 or higher, or taking medication, and its estimates apply the 2017 ACC/AHA criteria to national survey data from 2017 to March 2020. Under control is 22.5 percent, about 1 in 4.
CDC also reports that about 34 million adults who may need blood pressure medicine under the guidelines are not taking it. These numbers describe the whole country. Your own panel may look different, which is why step 1 starts with your own data.
Which Blood Pressure Number Counts as Controlled
| Source | Threshold | Where it applies |
|---|---|---|
| 2025 AHA/ACC guideline | Treatment goal below 130/80 mm Hg for all adults, with additional considerations for some groups | Clinical goal setting |
| HEDIS Controlling High Blood Pressure measure | Most recent reading in the measurement year below 140/90 mm Hg, in patients 18 to 85 with hypertension | Health plan quality reporting |
| CDC national estimates | High blood pressure defined as 130/80 or higher, applying the 2017 ACC/AHA criteria | National statistics |
A reading of 135/85 is above the guideline goal but below the HEDIS threshold, so the same patient can look controlled in one report and not in another. Know which number your contracts use, and keep the clinical goal in view. The HEDIS measure details are summarized by health plans such as Johns Hopkins Health Plans.
The 6 Steps at a Glance
How the steps map to the MAP framework
Measure accurately Steps 1 and 2: know your panel, and take accurate readings every time. | Act rapidly Step 3: standardize treatment with a protocol and team based care. | Partner with patients Steps 4 and 5: add home monitoring and remove barriers to care. | Run the loop Step 6: review data on a set schedule and act on it. |
MAP stands for Measure accurately, Act rapidly, and Partner with patients. It is an AMA quality improvement framework, described on the Million Hearts blood pressure control page.
Step 1: Know Your Panel and Your Measure
Start with a list of every patient with a hypertension diagnosis, and decide which measure you are improving. Then pull three lists from it.
| List | What it finds |
|---|---|
| Above goal at the last reading | Patients who may need a treatment review or closer follow up |
| No blood pressure on file in the measurement period | Patients who cannot count as controlled in a measure that needs a recent reading |
| Elevated reading with no follow up scheduled | Places where the loop is open between a high reading and the next action |
One published example used an early indicator measure: patients at goal, plus patients above goal with follow up scheduled in under six weeks, divided by the patients with hypertension seen in the office. The AAFP article describes it. An early indicator shows progress before the final control rate moves.
Step 2: Measure Blood Pressure Accurately Every Time
Every later step depends on reliable readings. The MAP framework calls for automated upper arm devices that are validated for clinical accuracy, and Million Hearts lists training the care team as a first change idea. In HEDIS, the most recent reading in the measurement year decides the result, so accuracy at the final visits matters.
Measurement checklist
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Step 3: Standardize Treatment With a Protocol and Team Based Care
A written protocol reduces variation between clinicians and makes follow up routine. The 2025 AHA/ACC guideline recommends a team based care approach for adults with uncontrolled hypertension. CDC describes team based care as clinicians working with pharmacists, community health workers, and other health professionals, and it supports the approach in its review of high blood pressure interventions.
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Source: American Journal of Hypertension, 2025. Electronic medical record IT tools were also among the top three strategies.
| Role | Example responsibilities |
|---|---|
| Clinician | Diagnosis, approving the protocol, and treatment decisions |
| Nurse or medical assistant | Accurate measurement, rechecks, follow up calls, and teaching home monitoring |
| Pharmacist | Medication review and adherence support within the practice protocol |
| Care coordinator or community health worker | Outreach, scheduling, and connecting patients with community resources |
| Quality or IT staff | The registry, reports, and dashboards |
Roles vary by practice and state law, and this table is an example and not guidance. One 10 practice family medicine department reported raising its control rate by 7.5 percentage points, to 78 percent, over two years after building a protocol with clear roles and early indicator measures, according to the same AAFP article.
Step 4: Add Home Blood Pressure Monitoring With Clinical Support
The 2025 guideline calls home blood pressure monitoring combined with frequent interactions with multidisciplinary team members “an important integrated tool to improve rates of blood pressure control.” CDC and Million Hearts also support self measured blood pressure monitoring with clinical support, which Million Hearts says may reduce therapeutic inertia and improve medication adherence.
Practices can support home monitoring through patient teaching and device access, or through Remote Patient Monitoring (RPM), where devices send readings to the care team. For quality reporting, health plan tip sheets state that readings taken by the patient with a digital device and documented in the record are acceptable, including during telephone and telehealth visits. Readings from manual devices taken by the patient are not.
Stage 1 Patient measures A reading taken with a validated digital device | Stage 2 Reading reaches the team By portal, phone call, or device transmission | Stage 3 Staff review Compared with the practice protocol on a set schedule | Stage 4 Clinician decides Treatment change, outreach, or a recheck, as the care team judges |
The example workflow above should be adapted to your practice. The guideline also advises against relying on cuffless devices, including smartwatches, until they show greater precision. Home monitoring is for routine monitoring between visits and does not replace emergency care, so patients should receive clear instructions from their clinician on when to seek urgent help.
Step 5: Remove Barriers to Taking Medicine and Getting Care
The guideline recommends an evidence based care plan that uses home monitoring and team based care responsive to adverse social determinants of health. In practice, that means asking why a patient is not at goal before changing the plan. The table lists common barriers with example responses.
| Barrier | Example practice response |
|---|---|
| Cost or coverage gaps | Ask a pharmacist or care coordinator to review coverage and lower cost options |
| Gaps in refills | Use refill reminders, and ask the clinician whether longer fills are appropriate. Health plan tip sheets suggest 90 day fills when appropriate |
| Difficulty getting to visits | Offer telephone or telehealth follow up where appropriate |
| Unclear instructions or concerns about medicines | Use follow up contacts to review the plan and answer questions, with a pharmacist where available |
| Social needs such as transportation | Connect patients with community resources through a care coordinator or community health worker |
Step 6: Review Data on a Set Schedule and Act on It
Data only helps if someone reviews it and acts. Name an owner, set a review schedule, and keep the list from step 1 current.
Monthly panel review
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Quick check: where to start
I do not know my control rate
Start with step 1. Build the registry and the three lists, and choose the measure you will report.
Office readings look high but I doubt them
Start with steps 2 and 4. Check device and technique, and consider home readings. Guidelines advise confirming a hypertension diagnosis with out of office measurements.
Patients improve and then slip
Look at steps 3 and 5. A protocol with scheduled follow up and attention to barriers can help keep patients engaged.
We have data but nothing changes
Focus on step 6. Assign an owner, set a monthly review, and make each review end with named actions.
How DrKumo Supports Home Blood Pressure Monitoring
Step 4 depends on getting reliable home readings to the care team. DrKumo provides secure, HIPAA compliant digital health technology that supports RPM programs operated by healthcare providers, using medical devices as defined by the FDA, such as blood pressure monitors. Readings move from the patient’s home to the care team over cellular connectivity, with no WiFi or smartphone app required. That may suit FQHCs and RHCs, rural health organizations, and community providers.
DrKumo also supports provider led, evidence based Disease Management Protocols for hypertension and applies healthcare cybersecurity practices to patient data. Which patients enroll, how readings are reviewed, and how treatment changes are made remain decisions for the care team. Practices can review DrKumo’s comprehensive guide to RPM. DrKumo is a technology provider and is not a clinical entity. Providers retain full clinical responsibility for patient care decisions, and RPM supports monitoring between visits rather than replacing emergency care.
Key Takeaways
Raising blood pressure control rates is a system task. The six steps are a registry and a chosen measure, accurate measurement, a protocol with team based care, home monitoring with clinical support, attention to barriers, and a regular data review.
The number that counts as controlled differs by source: below 130/80 in the 2025 AHA/ACC guideline and below 140/90 in the HEDIS measure. Know which one your contracts use.
Home monitoring with clinical support is recommended by CDC and the guideline, and RPM is one way to send readings to a care team. DrKumo’s technology supports RPM programs. DrKumo is a technology provider and is not a clinical entity, and RPM does not replace emergency care.
Data driven care starts here Planning a home blood pressure monitoring program? To learn how DrKumo can help your organization deliver secure, HIPAA compliant RPM, contact us today. Our team is ready to support your journey toward better patient care.
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Frequently Asked Questions About Blood Pressure Control Rates
Questions care teams ask about raising blood pressure control rates.
What blood pressure counts as controlled?
It depends on the source. The 2025 AHA/ACC guideline sets a treatment goal below 130/80 mm Hg for all adults, with additional considerations for some groups. The HEDIS Controlling High Blood Pressure measure counts a patient as controlled when the most recent reading in the measurement year is below 140/90 mm Hg. Check which number your contracts use.
What is team based care for hypertension?
CDC describes it as clinicians working with pharmacists, community health workers, and other health professionals to manage patients’ high blood pressure. The 2025 AHA/ACC guideline recommends a team based care approach for adults with uncontrolled hypertension.
Do home blood pressure readings count toward the HEDIS measure?
Health plan HEDIS tip sheets say readings taken by the patient with a digital device and documented in the medical record, including during telephone or telehealth visits, are acceptable. Readings from manual devices taken by the patient are not. Plans can differ in documentation expectations, so confirm with yours.
How long does it take to raise blood pressure control rates?
Timelines vary with starting rates, staffing, and how consistently the steps are applied. One family medicine department reported raising its control rate by 7.5 percentage points, to 78 percent, over two years.
Does home blood pressure monitoring help raise control rates?
CDC and the 2025 AHA/ACC guideline support home blood pressure monitoring with clinical support as a way to improve control. RPM is one way to send home readings to a care team. Results depend on how the team reviews the readings and acts on them.
References
Sources and method: this article was prepared from primary and professional sources, namely the 2025 AHA/ACC guideline, CDC data and program pages, Million Hearts, a peer reviewed analysis of Million Hearts Hypertension Control Champions, an AAFP practice case, and health plan summaries of the HEDIS measure. The table of example roles and the barrier responses are examples and not guidance. Information is current as of October 2026.
Jones, D. W., et al. (2025). 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Circulation.
Centers for Disease Control and Prevention. (2026). High Blood Pressure Facts. CDC.gov.
Centers for Disease Control and Prevention. Health and Economic Benefits of High Blood Pressure Interventions. CDC.gov.
Million Hearts. Blood Pressure Control. HHS.gov.
Strategies for Success: Million Hearts Hypertension Control Champions. (2025). American Journal of Hypertension, 38(9).
American Academy of Family Physicians. (2025). Saving Lives Through QI: Improving Blood Pressure Control in Primary Care. Family Practice Management.
Johns Hopkins Health Plans. Controlling High Blood Pressure (CBP) HEDIS measure. Johns Hopkins Medicine.
Disclaimer: This article is intended for informational purposes only and does not constitute medical advice. It describes system level steps for care teams and is not a substitute for clinical judgment, and diagnosis and treatment decisions remain with licensed clinicians. Quality measure specifications and guidelines are subject to change. Always consult the current specifications and your health plan contracts. DrKumo is a technology provider and is not a clinical entity. It does not provide clinical services or replace a licensed provider’s clinical judgment. Always consult with a licensed healthcare provider for guidance on diagnosis, treatment, or medical decisions. References to CDC, HHS, the American Heart Association, the American College of Cardiology, NCQA, and other organizations do not constitute or imply an endorsement by those organizations or the U.S. Government. |
