The innovative cardiovascular health program - cardiovascular disease (CVD), specifically heart disease and stroke, are among the top five leading causes of death in michigan, which has accounted…

The innovative cardiovascular health program - cardiovascular disease (CVD), specifically heart disease and stroke, are among the top five leading causes of death in michigan, which has accounted for 28% of deaths in 2021. Hypertension (HTN) is a controllable major risk factor of CVD. Flint is one of two cities in michigan with an estimated HTN prevalence of at least 53% at the census tract level. Greater flint health coalition (gfhc), mid-michigan community health access program (chap) and genesee health plan (GHP) have a strong presence and trust within the flint community. The michigan department of health and human services' (mdhhs) heart disease and stroke prevention unit (hdsp) will partner with these organizations to reduce the prevalence of HTN and CVD within flint census tracts with a HTN prevalence of at least 53% by reducing social determinant of health (sdoh) barriers. The purpose of this application is to demonstrate how hdsp will invest and engage in activities to improve cardiovascular health (CVH) within the approved flint census tracts. Under strategy 1, hdsp will work with gfhc and two federally qualified health centers (fqhcs) to track and manage unaddressed HTN in adults located within the selected census tracts using the EHR and improve social needs screening assessments and linking them to the correct sdoh-related z-codes. In addition, hdsp will further develop its chronic disease registry, chronicle, by allowing entry of data sources such as death records, EMS data, social needs data, and EHR data for the medicaid population to not only advance michigan's capacity for surveillance but also to explore linkages to locally collected data to increase clinical and social integration. Hdsp will also promote the use of findhelp mid-michigan to document referrals made to chap. Under strategy 2, hdsp will work with chap to expand health information systems to coordinate the care management by community health workers (chws), nurses, and social workers for patients referred to c HAP. With the medicaid quality improvement and program development section, hdsp will expand a standardized sdoh screener template utilized by health plans and provide technical assistance to medicaid health plan quality improvement directors on how to equip their providers with care teams that can produce system-level quality improvement for controlling HTN. Hdsp will also help facilitate gfhc's development of a learning collaborative to identify and address barriers that affect residents' health and explore opportunities to improve health outcomes through social care coordination, further expand the use of the findhelp platform, and utilize data from chronicle to explore gaps in services which will inform recruitment of new social service providers. Under strategy 3, hdsp will build gfhc's capacity to facilitate links between clinical providers and community partners by increasing the number of partners IT works with and ensure that the partners are able to communicate effectively to improve the health and well-being of the individuals they serve. Hdsp will work with GHP to have a CHW conduct social needs assessments at a community outreach center. GHP will also build capacity among its members for self-measured blood pressure monitoring by incorporating the healthy heart ambassador blood pressure self-monitoring program at two sites. As a policy-level intervention, hdsp will collaborate with mdhhs' office of policy and planning to support non-profit employers in training eligible employees as chws in high burden areas. All strategies will contribute to improving blood pressure control in health care and community settings, reduce disparities in blood pressure and blood cholesterol control, and increase utilization of social services and support among adults within the approved flint census tracts. By achieving these outcomes, hdsp hopes to see improved CVH and reduced CVH disparities among the most burdened communities.