The cardiovascular health innovation program (CHIP) - the risk and burden of cardiovascular disease (CVD) is not equally shared

CVD is the leading cause of death in the united states and new york city (NYC), and persistent disparities in prevalence and outcomes have only widened among racial and ethnic groups and historically marginalized populations. These disparities are caused by the social determinants of health (SDOH) and institutional racism. Effective action - increasing access to resources for social determinants and proven effective programs that have been tailored for the community - requires investing specifically in historically DIS-invested communities, increasing access to evidence-based interventions, and addressing the SDOH. The cardiovascular health innovation program, referred to as "CHIP", is a NYC department of health and mental hygiene (DOHMH) place-based initiative that targets NYC historically marginalized populations, particularly black populations, at greatest risk for CVD and related poor outcomes, defined through census tracts with prevalence of hypertension (HTN) greater than 53%. DOHMH will maximize use of existing programs/services and through technical assistance, training, coaching, and contracts for direct service delivery to build infrastructure, fill the gaps to improve and promote equity in CVD outcomes. Using a collective impact approach, DOHMH will partner with 3 community and 65 clinical organizations to implement an array of evidenced-based approaches (i.e., optimizing/using/advancing electronic health records [EHR]; health information technology [HIT]; GIS or other GEO-mapping tools; team-based care; SDOH screening, referral, and referral follow-up; self-measured blood pressure monitoring with clinical support; clinical-community linkages; and community health workers) to identify, track, and address and/or improve CVD care, outcomes and SDOH needs. DOHMH will also build a data-driven and action-oriented learning collaborative comprised of multidisciplinary stakeholders to support improvement efforts and conduct a rigorous process and outcomes evaluations of program strategies. In five years, CHIP will reach nearly 261,118 adults from the population of focus. Overall HTN control will increase by over 17% (from 67.5% to 79%). HTN control among the black population will increase almost 25% (from 61.8% to 76.9%). Disparities in HTN control between the two groups with the highest HTN control at baseline, asian (77.3%) and white (71.6%) adults compared to black (61.8%) adults, who have the lowest rate, will decrease by 12.4% and 6.7% points, respectively. 7,605 adults will be referred to and access social support services. Additionally, CHIP will achieve the following: all 65 clinics will have policies/protocols in place requiring the use of ehrs and standardized clinical quality measures to track HTN control measures by race, ethnicity, and other populations of focus; 52 (80%) of clinics will use standardized processes or tools to identify, assess, track, and address the social services support needs; all 65 clinics will have policies/protocols in place requiring the use of clinical data from ehrs or HIT to support communication within the care team to coordinate care for HTN and high cholesterol; 239,368 adults will be served by clinics that use multidisciplinary care teams that adhere to evidence-based guidelines; there will be 3,050 social services and 222 type of social services that address social needs; 17,500 adults will be referred to lifestyle change programs or social services and support; 75 chws (or their equivalent) will engage with community organizations to provide a continuum of care by extending clinical interventions and addressing social services and support needs; and 132,610 adults will participate in self-measured blood pressure monitoring with clinical support.