Rhode island cardiovascular health program - rhode island department of health's (ridoh) diabetes, heart disease and stroke (ridhds) program is centrally located at 3 capitol hill in providence, RI

Ridoh is committed to serving all populations and communities within the state to provide every rhode islander an equal opportunity to be as healthy as possible. Ridhds is further committed to addressing chronic disease statewide and will utilize funding opportunity CDC-RFA-DP-23-0004 to build upon the accomplishments achieved in DP18-1815 and DP18-1817. Ridhds will concentrate efforts on extending evidence-based strategies and implementing new strategies and activities, aimed at preventing and managing cardiovascular disease (CVD) in high-burden populations. Ridhds has identified as its priority population, adults who are below 400% of the federal poverty level, with an additional focus on reducing racial and ethnic disparities throughout the state. The proposed priority populations are disproportionately diagnosed with hypertension and high cholesterol, and commonly identified with CVD risk factors and social needs. Ridhds will address CVD risk, burden, and social needs among priority populations by creating and implementing a comprehensive learning collaborative. The learning collaborative will leverage partnerships within health systems to improve quality of care and outcomes for patients with hypertension and high cholesterol through increased use of electronic health records (EHR) or health information technology (HIT) and team-based care. The collaborative will also provide an opportunity to advance existing clinical-community linkages to reduce health disparities and address social services and support needs of priority populations. Alongside and as part of the learning collaborative, ridhds will: (1) continue operations of the community health network (CHN) as a referral system for eblps and expand its capabilities for bidirectional feedback of patient outcomes and tracking of participation barriers and social needs, (2) strengthen the skillset of certified community health workers (cchw) and expand their involvement in continuum of care for CVD prevention and management, and (3) scale and sustain the delivery of healthy heart ambassador blood pressure self-monitoring by expanding the number of sites, supporting systemic referrals through learning collaborative teams, and cross-training program facilitators as chws. The approach taken by ridhds will lead to the following outcomes by the end of the project period: (1) increased use of ehrs/HIT to report, monitor, and track clinical and social services and support needs data; (2) increased use of standardized processes or tools to identify, assess, track, and address the social services and support needs of patient populations; (3) increased use of ehrs or HIT to support communication and coordination among care team members to monitor and address patient' hypertension and high cholesterol; (4) 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; (5) increased multidisciplinary partnerships that address identified barriers to social services and support needs within target populations; (6) increased community clinical links to identify and respond to social services and support needs of target populations; (7) increased engagement of chws to provide a continuum of care extending clinical interventions and addressing social services and support needs; (8) increased use of smbp with clinical support within populations at highest risk of hypertension; (9) improved blood pressure control among populations within partner health care and community settings; (10) reduced disparities in hypertension control among populations within partner health care and community settings; (11) increased utilization of social services and support among target populations.