NC national cardiovascular health program - the community and clinical connections for prevention and health branch (CCCPH) within the NC department of health and human services is physically…

NC national cardiovascular health program - the community and clinical connections for prevention and health branch (CCCPH) within the NC department of health and human services is physically located at 5505 six forks RD., raleigh, NC and will lead implementation of 23-0004 strategies throughout north carolina (NC). CCCPH will improve the prevention and management of cardiovascular disease (CVD) for populations at disproportionate risk for CVD morbidity and mortality in NC. The strategies proposed aim to implement evidence-based/informed activities to address both physical and social determinant of health risk factors for CVD in areas of the state with high CVD mortality and morbidity rates. CCCPH will develop new activities as well as expand partner networks and activities previously established under 1815 funding. Short-term outcomes by strategy: strategy 1: 1) increased use of electronic health records (EHRS) or health information technology (HIT) to report, monitor, and track clinical and social services and support needs data to improve detection of health care disparities and the identification, management, and treatment of patients at highest risk of CVD, with a focus on hypertension and high cholesterol; and 2) increased use of standardized processes or tools to identify, assess, track, and address the social services and support needs of patient populations at highest risk of CVD. Strategy 2: 1) increased use of EHRS or HIT to support communication and coordination among care team members to monitor and address patients' hypertension and high cholesterol; 2) increased use of multidisciplinary care teams adhering to evidence-based guidelines to address patients' social services and support needs and improve the management and treatment of hypertension and high cholesterol; and 3) increased multidisciplinary partnerships that address identified barriers to social services and support needs within populations at highest risk of CVD. Strategy 3: 1) increased community clinical links to identify and respond to social services and support needs of populations at highest risk of CVD with a focus on hypertension and high cholesterol; 2) increased engagement of community health workers (CHWS), or their equivalents, to provide a continuum of care extending clinical interventions and addressing social services and support needs; and 3) increased use of self-measurement of blood pressure (SMBP) with clinical support within populations at highest risk of hypertension. Intermediate outcomes: 1) improved blood pressure control among populations within partner healthcare and community settings: 2) reduced disparities in hypertension control among populations within partner healthcare and community settings; and 3) increased utilization of social services and support among populations at highest risk of CVD, with a focus on hypertension and high cholesterol. Long-term outcomes: 1) improved cardiovascular health; and 2) reduced disparities in cardiovascular health.