Ccme grant application to CDC-RFA-DP-23-0005 - our project aims to address longstanding cardiovascular disease (CVD) disparities and promote health equity by identifying gaps in the prevention,…

Ccme grant application to CDC-RFA-DP-23-0005 - our project aims to address longstanding cardiovascular disease (CVD) disparities and promote health equity by identifying gaps in the prevention, screening, treatment, and self-management of CVD in areas where hypertension (HTN) is 53% or higher in the southeast region of the united states. To achieve this, we will expand the successful 4-C learning collaboratives (LC) across the region to (1) educate healthcare providers on evidence-based CVD best practices and create peer-to-peer sharing opportunities; (2) develop electronic health record (EHR) workflow optimization and disease management detection and monitoring for improved clinical outcomes; and (3) launch a community of care hub (COC hub) to connect patients with local social supports. We will identify our target population using CDC places for GIS mapping to examine HTN prevalence at the census tract level, allowing US to identify tracts with HTN at 53% or higher. The preliminary analysis identifies 92 census tracts meeting the 53% HTN crude prevalence rate in the four target states in the southeast. This information and our collaborative relationships will aid in recruiting providers and LC members and expand our reach to relevant community-based organizations (CBO) to address social determinants of health (SDOH). We will also use a multidisciplinary approach to deliver patient care and peer learning by CO-locating a pharmacist in provider offices and establishing an HTN and CVD extension for community healthcare outcomes (ECHO). Primary outcomes to be measured are (1) the increased detection of hypertension and hyperlipidemia, (2) the number of providers who adopt self-monitoring blood pressure as an evidence-based best practice in the treatment of HTN (3) the number of referrals to the COC hub, and (4) the number of closed loops from the COC hub connecting patients with appropriate social supports. In accordance with ccme data security policy, outcomes 1 and 2 will be measured using P atient data from the provider's ehrs, which will be made available by provider participants for quarterly analysis. Outcomes 3 and 4 will also be measured quarterly using data from the COC hub's workshop wizard data platform. This project will engage populations with substantial healthcare disparities and gaps in the receipt of healthcare. Results will advance dissemination to providers working with similar populations and potentially reduce health disparities and improve healthcare for millions.