NU58DP007431

The National Cardiovascular Health Program - Problem: Heart disease and stroke are among the leading causes of death in Connecticut (CT). An estimated 31.6% of CT adults have been told by a health professional that they have high blood pressure. Approximately 34.9% of adults have been told by a health professional that it was high.

Early identification and intervention, including clinically supported self-management, will help people with these chronic conditions improve their health and reduce their risk for serious, life-threatening complications.

Project outcomes: With CDC-RFA-DP-23-0004 funding, the CT Department of Public Health (DPH), located in Hartford, CT, proposes to build on current CDC-RFA-DP18-1815 grant activities. The focus will be communities with high burden of cardiovascular disease (CVD), its risk factors, and related complications to improve access to screening, health care services, and community support that assist overall wellness.

As a result of proposed activities, CTDPH expects to achieve an increase in the use of electronic health records/health information technology (HER/HIT) and standardized processes and tools to address social services and support needs of patients at highest risk of CVD. Increase communication among care team members and support multidisciplinary care teams' adherence to guidelines to address patients' hypertension and high cholesterol. Increase community-clinical partnerships and links, including engaging community health workers (CHWs) and the use of self-measured blood pressure (SMBP) with clinical support, to reduce barriers and respond to social services and support needs.

Intermediate term outcomes include: improved and reduced disparities in BP control among populations within partner health care and community settings and increased use of social services and support among populations at highest risk of CVD with a focus on hypertension and high cholesterol.

Project strategies/activities: Working with a contractor, CTDPH will create a statewide cardiovascular (CV) health learning collaborative (LC) that invites participation from both health care organizations (HCOS) and community-based organizations (CBOS) that engage with populations most at risk for CVD, with a focus on hypertension and high cholesterol. The LC will address HCOS system needs required to support best practice in care and disease prevention, including EHR improvements to track clinical and social services and support needs and to support team-based care and advance community-clinical linkages, including use of CHWs by improving their sustainability by building or strengthening a supportive infrastructure to expand their involvement in evidence-based CVD prevention and management programs and services.

The LC will facilitate communication and the exchange of ideas among health agencies, leverage technical and financial resources to support improvements in CV health outcomes, and increase awareness of social services and supports that aim to reduce social determinants of health (SDOH)-related barriers to care, using these strategies:

1) Track and monitor clinical and social services and support needs measures shown to improve health and wellness, health care quality, and identify patients at highest risk of CVD with a focus on hypertension and high cholesterol.

2) Implement team-based care to prevent and reduce CVD risk with a focus on hypertension and high cholesterol prevention, detection, control, and management through mitigation of social support barriers to improve outcomes.

3) Link community resources and clinical services that support bi-directional referrals, self-management, and lifestyle change to address social determinants that put priority population at increased risk of CVD, with a focus on hypertension and high cholesterol.

Coordination: Grant evaluation will be coordinated with UCONN Health. Activities will be designed to have a statewide impact, including early identification, screening, referrals, and tracking of patient outcomes, with efforts to address SDOH.

Connecticut Department Of Public Health

NOT APPLICABLE

93.945 - Assistance Programs for Chronic Disease Prevention and Control

CDC Office of Financial Resources (OFR) [HHS - CDC]

National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) [HHS - CDC]

Connecticut United States

State-Wide

The National Cardiovascular Health Program (CDC-RFA-DP-23-0004)

Amendment Since initial award the total obligations have increased 310% from $946,106 to $3,879,035.