The national cardiovascular health program - in north dakota, the most vulnerable and underserved populations suffer from the highest rates of cardiovascular disease (CVD) with lower rates of control

Income-related inequalities drive much of the disparity seen in chronic disease data nationally, and the frontier nature of north dakota's landscape provides an additional barrier for individuals to access healthcare and social services. This application leverages collaboration between internal and external partners to develop and implement sustainable policies and system changes to better address the needs of all north dakotans with or at-risk for CVD, especially those experiencing low socioeconomic status (SES). Anticipated outcomes include, but are not limited to, systematic identification and addressing of social services needs for persons with or at risk for CVD, increased utilization and collaboration of multidisciplinary care teams to improve management of CVD, and enhanced coordination of clinical and community services to address needs of patients with CVD. Opportunities exist for the north dakota department of health and human services (dhhs) to strengthen statewide approaches to CVD management. To address the social determinants of health (sdoh) that reduce individuals' capacity to effectively manage their chronic disease diagnosis or risk, and to impact health disparities that exist among north dakotans with CVD, implementation of statewide infrastructure to support BI-directional communication and shared health outcomes and social services needs data tracking between clinical and community organizations is needed and will be a strategy approach of the north dakota dhhs. North dakota dhhs's proposed work to meet the intended outcomes of CDC-RFA-DP-23-0004 the national cardiovascular health program will require a wide variety of current, new, and expanded partnerships. Partnerships will include health systems, pharmacies, local public health, and community-based organizations. The north dakota dhhs has the capacity to serve all populations and communities within the state. Ongoing collaboration with three of the five tertiary health systems will generate system-level changes that affect approximately 75% of north dakota's population. In addition, a long-standing partnership with an expansive network of federally qualified health centers will result in improved quality of care for a patient population of primarily low SES.