Innovative solutions for cardiovascular health - the innovative solutions for cardiovascular health (isch) project will unite the LOS angeles department of public health, the community clinic…

Innovative solutions for cardiovascular health - the innovative solutions for cardiovascular health (isch) project will unite the LOS angeles department of public health, the community clinic association of LOS angeles county, the university of southern california (USC) alfred e. Mann school of pharmacy and pharmaceutical sciences, the USC gehr family center for health systems science and innovation, local federally qualified health centers and community health centers, and community-focused partners to develop a comprehensive, multi-pronged program that will facilitate system-level changes that reduce health and health care disparities by bridging gaps in equity that impact local communities most at risk for developing cardiovascular disease. Isch will focus its work in two census tracts where the overall crude hypertension prevalence among adults is 53% or higher, based on the CDC's places. These census tracts have a higher proportion of black residents, higher numbers of people experiencing homelessness, and higher rates of poverty, when compared to the rest of LOS angeles county (LAC). Residents of these communities are over-burdened by critical, social needs (e.g., lack of affordable housing, need for food assistance, transportation barriers, etc.), which can inhibit them from managing chronic conditions, such as hypertension. Where feasible, isch will expand these efforts to also improve the health outcomes for at-risk individuals and groups from other areas and communities in LAC, based on health indicators from other data sources. Isch will build upon the momentum of the 2014-2018 chronic disease prevention strategy (CDC 1422 initiative) and the 2018-2023 solutions for healthier communities (CDC 1817 initiative) to implement a targeted, integrated model of chronic disease prevention and control. Isch will undertake a variety of activities, such as utilization of community resource referral platforms, GIS mapping, coalition building, self-measured blood pressure monitoring, and the use of pharmacists and community health workers, in order to better understand and support the needs of target communities. Through organizational practices, health information technology, training and technical assistance, and leveraging of key interventions, isch intends to scale programs and disseminate best practices for integrating social support, health education, and clinical care delivery designed to prevent or control hypertension and high cholesterol within approved populations of focus. Isch will accomplish these goals by executing the three strategies outlined in DP-23-0005 notice of funding opportunity. They will be implemented at clinic and community sites serving populations of high hypertension prevalence and disproportionately affected by factors related to the social determinants of health. Resources and lessons learned from implementing these strategies will be disseminated amongst a broad network of partners, so that they may be replicated to address health disparities throughout LAC. By project end, these mutually reinforcing strategies should result in increased access to social services and related supports, enhanced integration of medical and social service delivery, and improved blood pressure and cholesterol control within the highest burden populations in LAC.