NU58DP007595

Virginia Innovative Cardiovascular Health Program - Virginia faces a public health crisis as cardiovascular disease (CVD) has risen to the leading cause of death in the Commonwealth since 2019. Roughly 4,458,264 adults 18 years and older in Virginia are living with hypertension, the leading risk factor of CVD.

Poor blood pressure control, healthcare access, medication adherence, and screening are key reasons for increased risk for CVD. The barriers to improved CVD risk stem are exacerbated by the adverse social conditions that hinder the control of hypertension, including poverty, food and housing insecurity, poor transportation, and low educational attainment.

African Americans disproportionately experience these adverse social conditions, and higher rates of CVD morbidity and mortality. In Virginia, there are 11 census tracts (neighborhoods) with a hypertension prevalence crude rate of greater than 53%. Among these census tracts, the majority of residents are African Americans, female, and low-income.

Each census tract is among the lowest on the Health Opportunity Index scale, a composite score of indices from the built environment, consumer opportunity, economic opportunity, and social impact.

The Virginia Innovative Cardiovascular Health Program (VICHP) proposal focuses efforts on identifying and responding to health care disparities and improving health outcomes, specifically for individuals with hypertension and high cholesterol, and those at highest risk for CVD.

The VICHP proposal emphasizes achieving impact and reach across these 11 census tracts where disparate populations can benefit from the strategies included in CDC DP23-0005. The goals will be achieved by leveraging the Virginia Heart Disease and Stroke Learning Collaborative (VHDS LC) to convene local learning collaboratives and aligning strategies and metrics for the highest impact and reach.

These activities include:
1) The utilization of geo-mapping tools and health information technology to guide and assist health systems and local collaboratives to identify target populations;
2) Integration and use of health information systems and multidisciplinary teams that include community health workers and doulas to scale the chronic care management model for Medicare patients and for postpartum women for up to 12 months of Medicaid coverage through a Medicaid Chronic Care Management Pilot Program;
3) Leveraging clinical-community links to increase referrals to the Healthy Heart Ambassador Blood Pressure Self-Monitoring Program (HHA BPSM), and social services and supports for patients based on their social determinants, such as healthcare access, poverty, food insecurity, housing insecurity, and health literacy.

Given that the majority of residents within the 11 census tracts are women and African American, and the reality that Black mothers experience higher rates of death, the VICHP will also partner with doulas to offer the HHA BPSM program, utilize the Unite Us statewide referral system to screen for social determinants of health and refer to community resources, and enroll in a Medicaid Chronic Care Management Pilot Program for the comprehensive goal of empowering Black mothers to self-monitor blood pressure, gain access to needed services and supports, and manage CVD-related illnesses that increase risk for CVD.

Over the 5-year period, VDH will scale and sustain successful and comprehensive interventions and local collaborations by 2028. Through leveraging existing resources at state and local levels, building capacity in key stakeholders at the census tract level, and coordinating clinical and community interventions in a mutually-reinforcing approach, this proposal provides the public health response critical for mitigating the widespread CVD, risk factors, and health disparities both in these census tracts with immediate scale and reach to all Virginia residents through the VHDS LC.

Virginia Department Of 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]

Virginia United States

State-Wide

The Innovative Cardiovascular Health Program (CDC-RFA-DP-23-0005)

Amendment Since initial award the total obligations have increased 200% from $1,200,000 to $3,600,000.