Purba, Very interesting idea. As I reflect on your translatable idea, I think about the cultural differences between KP (strong administrative support and multi-pronged approach to wellness) and SFGH (dedicated staff that are under-resourced). That said, decades ago I was the director of a hypertension education program at La Clinica de la Raza in Oakland, which serves mostly the uninsured patients (similar to patients at SFGH). We were able to intensify BP management through provider training, protocol development, pharmacy involvement, nurse/nutrition case managers, and community health education programs (we started a farmers market in E. Oakland, at a time when you couldn't find a farmer's market in the East Bay if you tried). We had tremendous buy-in (a lot of grant money is a wonderful thing!) and I think the program was a great success. I think the external factors and the framework that you describe are on the mark.
I was wondering, do you think that therapeutic inertia contains an element of frustration that the patient will not "get better no matter how hard I try"? Patient compliance might need to be addressed in providers' perceived behavioral control.