The Rhode Island Department of Health Diabetes, Heart Disease, and Stroke (RIDHDS) Program will utilize funding opportunity MP-CPI-24-001 to apply knowledge from past and existing quality improvement and community initiatives to develop the project Providence Community Advisory Network (Providence CAN). The Providence Community Advisory Network will be formed and convened monthly in Year 1 and quarterly thereafter and will consist of members of the population of focus, community-based organizations that directly represent and serve the population of focus, CHWs, and clinicians to inform and engage in the project design, implementation, and evaluation. This inclusion will allow RIDHDS and contributing partners to thoughtfully address racial, ethnic, socioeconomic, and other social determinants of health (SDOH) that exist among the population of focus and to contribute to disparities in heart disease, hypertension (HTN), and diabetes. The goal of Providence CAN project is to improve HTN management and diabetes prevention among Providence residents that are served by the four safety-net clinics, three Providence-based HEZs, and their subnetworks of community-based partners.
In Rhode Island, heart disease is the leading cause of death, while diabetes is the 8th leading cause of death. Within this statistic, demographic and economic disparities exist among those who are diagnosed with coronary heart disease and diabetes. RIDHDS is proposing to build a Network of community and clinical partners to close the disparities and decrease prevalence of chronic disease across RI. The project will develop, implement, and evaluate community-level innovations including: (1) the community-led Network with trusted messengers, (2) CHW clinical interventions within the Network, and (3) mini-grant opportunities from the Network that will reflect the cultural and linguistic preferences of the population of focus. Providence CAN will catalyze community engagement to reduce barriers to the Healthy People 2030 SDOH Domains for (1) “Social and Community Context” and (2) “Health Care Access and Quality” and make progress toward Health People 2030 Leading Health Indicators (LHI) targets for (1) hypertension (Increase the proportion of adults with hypertension whose blood pressure is under control) and (2) diabetes prevention (Reduce the annual number of new cases of diagnosed diabetes in the population).
The RIDHDS approach will leverage current partnerships with the Providence Health Equity Zones (HEZ), community-based organizations, community members, and the safety-net clinics. These existing networks and relationships indicate that the Providence community well positioned to establish a collaborative community network to co-design and implement project activities to strengthen and reduce barriers to community support services and resources and connect individuals to preventive health services through community-level innovations. RIDHDS will also build on existing partnerships with the Community Health Worker Association of Rhode Island to support the CHW workforce, the Care Transformation Collaborative of Rhode Island for project support, Advocates for Human Potential for EHR/HIT support, and Brown University for evaluation support.