Minnesota cardiovascular health innovation project (mnchip) - minnesota (MN) has glaring disparities in cardiovascular disease (CVD) deaths, hospitalizations, and risk factors that…

Minnesota cardiovascular health innovation project (mnchip) - minnesota (MN) has glaring disparities in cardiovascular disease (CVD) deaths, hospitalizations, and risk factors that disproportionately impact communities of color in our state. Many communities experience systemic barriers that lead to higher disease burden and associated health data disparities. American indian and black communities in MN notably experience high burdens due to heart disease and stroke. When compared to the overall population in MN, the age-adjusted hospitalization rate for heart disease is 60% higher for black people and twice as high for american indians. Overall, black and american indian minnesotans between 35 and 64 years DIE from heart disease at a rate approximately two to four times higher than minnesotans overall. These racial health inequities were most pronounced in socially-vulnerable neighborhoods with reduced access to health care services. The CDC DP-23-0005 FOA is an opportunity for MN to build on the extensive work accomplished to date through the 1815 and 1817 CDC grants. Our proposed activities for DP-23-0005 build upon the foundational CDC DP-23-0004 FOA by launching tailored initiatives for populations of focus, namely geographic communities experiencing the highest burden of hypertension in MN. The proposed activities will be guided by a learning collaborative (LC) using a community engaged approach. The LC will identify barriers to positive health outcomes and opportunities to CO-create solutions to be tested and evaluated for impact. Our efforts will focus on two communities with crude prevalence of hypertension greater than 53%. The first urban community is a group of four neighboring census tracts in the city of ST. Paul largely incorporating the rondo community. Rondo is the historic heart of ST. Paul's african american community which was systematically destroyed by the construction of interstate 94 during the 1950's and 1960's. The second rural community is a geographically large census tract in far northern MN, incorporating the populated sections of the reservation lands of the bois forte band of chippewa and adjacent rural communities, among the most remote in our state. We intend to advance and promote the effective use of electronic health records and health information technology to address inequities in CVD outcomes, and expand use of geographic information systems (GIS) to identify populations of focus as well as visualize the impact of state and community-led work to improve health outcome. Building upon robust data systems, we will reinforce person-centered multidisciplinary teams in support of patient care to meet health goals, screen and refer patients for social determinants of health, and deliver the appropriate social supports to improve overall well-being and positive cardiovascular health outcomes. Through these data and team-based-based approaches, we will strengthen and formalize the links between clinical and community settings, moving toward comprehensive BI-directional referral and follow-up systems. Through our LC we intend to broaden the reach and impact of the DP-23-0005 work in these communities to reach across geographic locations in our state.