Montana cardiovascular health program - the montana department of public health & human services' (MT dphhs) montana cardiovascular health program (cvhp) is applying for the CDC-RFA-DP-23-004 to…

Montana cardiovascular health program - the montana department of public health & human services' (MT dphhs) montana cardiovascular health program (cvhp) is applying for the CDC-RFA-DP-23-004 to address the burden of cardiovascular disease (CVD) statewide, particularly hypertension and high cholesterol. The work will include all residents of the state of montana with a specific focus on american indians, veterans, people with a disability, residents living in rural/frontier areas, and low-income montanans including those on medicaid. The cvhp offices are located at 1400 broadway street, cogswell building, C314 b, helena, MT 59601. The cvhp has the capability to serve all populations and communities across montana. The cvhp will improve the health of all montanans by achieving the outcomes described in this funding opportunity. The cvhp has a long history of providing heart disease and stroke prevention and management programming and services to the entire state with a focus on hypertension and high cholesterol since 2009. This includes long-standing partnerships, well-trained and experienced staff, and a committed stroke workgroup. The CVH will implement activities through a comprehensive, inclusive, and coordinated approach to expand health equity efforts in clinical and community settings. These activities will occur statewide with increased focus on priority populations, including those living in high burden areas or those who are at high-risk that may otherwise be missed by these activities. Continued surveillance and evaluation activities will be used to monitor progress, analyze outcomes, perform quality improvement, and report success. With strategies 1A and 1B, funded clinics and larger health systems will select and use a social determinants of health (sdoh) screener, document z codes in the electronic health record (EHR) problem list for patients, and monitor referrals of patients to community-based programs addressing social services and support needs. They also will use population health data to assess health disparities in targeted populations. For strategies 2A and 2B, the larger health systems will integrate the sdoh screener within the EHR to enhance team-based communication and will expand their team to include community-based partners. In strategy 2C, the cvhp will form a 2304 learning collaborative to review priority population data, help identify statewide health equity goals, and determine ways to address barriers to social services and support needs. For strategy 3A, community-clinical links will be established via a bidirectional referral system, and health coaches for hypertension control classes will be implemented in nine communities. With strategy 3B, community health representatives will identify social needs of tribal members and refer them to community resources, and community health workers affiliated with larger health systems will link patients with housing instability to housing assistance. Strategy 3C involves implementing blood pressure cuff loaner programs in community pharmacies, labor & delivery units, urban indian health centers, tribal colleges, community libraries and with healthcare professionals such as dentists. The proposed 2304 projects will enhance communication and integration of montana health systems and community organizations to better address social services and support needs of those at highest risk of CVD. These strategies also will help improve health outcomes and health equity long-term.