South carolina's national cardiovascular health program - the purpose of this initiative is to leverage technical and financial resources to support programs and resources to improve cardiovascular…

South carolina's national cardiovascular health program - the purpose of this initiative is to leverage technical and financial resources to support programs and resources to improve cardiovascular (CVD) health outcomes for those at highest risk of CVD. This will be accomplished through the implementation of a strategic partnership with the south carolina hospital association, south carolina office of rural health and accesshealth SC to build upon the existing diabetes learning collaborative funded by the duke endowment and expand the scope to include a focus on CVD health. South carolina's application builds and expands upon the accomplishments and outcomes achieved from previously funded CDC grants (1305, 1422, 1815, 1817). The south carolina department of health and environmental control's (dhec's) central office is located at 2600 bull street, columbia, SC, 29201. Dhec and ddhdm havea statewide presence, history and experience implementing federal grants which demonstratesour capacity to serve all south carolinians. Dhec and ddhdm havea statewide presence, history and experience implementing federal grants which demonstratesour capacity to serve all south carolinians. This proposal addresses the challenges and health inequities in priority populations disproportionally impacted by CVD. Dhec is committed to taking proactive approach to address health equity gaps and reduce disparities. The office of diversity equity and inclusion within the PH deputy area is aligned with the agency's core value of advancing equity and will serve as a resource for the implementation of this grant. This application supports investments in implementing and evaluating a learning collaborative focused on improving health outcomes for people at highest risk of CVD. Additionally, internal, and external partners will assist AH enrollees with accessing social services and support needs. Ddhdm will use a data driven approach and GIS-mapping to focus efforts on priority populations. The activities outlined in the work plan build upon ahsc's existing learning collaborative infrastructure (i.e., data disaggregation, learning sessions, and performance improvement coaching) using results based accountability. This approach will be used to yield equitable outcomes of the strategies. Through this funding opportunity, SC will intentionally build synergy between strategies to improve health outcomesforpopulations most at risk for CVD. During the period of performance, some of the expected short-term outcomes for the strategies include: 1)increased use of ehrs or HIT to improve detection of health care disparities and the communication and coordination among funded AH care team members; 2) increased use of standardized processes or tools to address the social services and support needs of patient populations at highest risk of CVD; 3) increased use of multidisciplinary care teams within funded AH networks adhering to evidence-based guidelines and identifying barriers to social services and support needs among populations at highest risk of CVD; 4) increase 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; 5) increased engagement of funded AH community health workers to provide a continuum of care extending clinical interventions and addressing social services and support needs; and 6) increased use of self-monitoring blood pressure programs with clinical support within populations at highest risk of hypertension. Additional intermediate outcomes anticipated by ddhdm are to increase the reach of AH networks in underserved areas with a large population of uninsured patients and decrease CVD related hospitalization use and/or costs among funded AH network enrollees. Where possible, ddhdm will leverage partnerships (e.g., wisewoman) to maximize reach of program implementation and data collection. The ddhdm implementation approach provides the necessary program management, coordination