Ukhc's innovative cardiovascular health program - cardiovascular disease (CVD) was the leading cause of death in kentucky in 2019

The state faces a series of barriers that impede progress in reducing the impact of cardiovascular disease on the population of the commonwealth. Between 2017 and 2021, kentucky is estimated to have a rate of 1,510 CVD deaths per every 100,000 persons, if no preventative intervention occurs (million hearts webpage 2019). This proposal is intended to improve the health outcomes of adults aged 18 and older through the implementation of a learning collaborative that targets impacted census tracts in christian, mccracken, and jefferson counties in kentucky with a hypertension crude prevalence rate of 53% or higher to focus on those at highest risk for cardiovascular events. With 20 eligible census tracts, kentucky ranks 10TH for having the highest number of census tracts that meet the criteria of having a crude prevalence rate of 53% or higher for hypertension among all states and territories (CDC places data portal 2022). Interventions to address hypertension and high cholesterol will be tailored to high-risk patient populations experiencing various social determinants of health and will be integrated at the practice level by recruiting practices in areas with the highest rates of CVD. This project will deliver a collaborative framework of resources that will be shared with an expanded network of practices to improve outcomes and reduce CVD prevalence within communities with the highest rates of hypertension and high cholesterol. The proposed project is designed to achieve the following outcomes: - increase the use of ehrs and HIT to report, monitor, and track clinical data and social services and support needs to improve detection of health care disparities and the identification, management, and treatment within the populations of focus. - increase use of standardized processes or tools, such as GIS or other GEO-mapping tools, to identify, assess, track, and address the social services and support needs within populations of focus. - increase the use of health information systems to support communication and coordination among care team members to monitor and address hypertension and high cholesterol within approved populations of focus. - increase use of multidisciplinary care teams adhering to evidence-based guidelines to address social services and support needs within approved populations of focus. - increase multidisciplinary partnerships that address identified barriers and social services and support needs within approved populations of focus. - increase community clinical links and respond to social services and support needs within approved populations of focus. - increase engagement of chws (or equivalent) to provide a continuum of care by extending clinical interventions and addressing social services and support needs within the populations of focus. - increase the use of smbp with clinical support within populations of focus. - improve blood pressure control among populations within partner health care and community settings. - reduce disparities in blood pressure control among populations within partner health care and community settings. - increase utilization of social support services among populations of focus