Maryland Cardiovascular Disease Program - Center for Chronic Disease Prevention and Control, Maryland Department of Health, 201 W. Preston St, Baltimore, Maryland, 21201 The Maryland Department of Health’s (MDH) Center for Chronic Disease Prevention and Control (the Center) is applying for the CDC funding opportunity, “The National Cardiovascular Program,” offered by the Centers for Disease Control and Prevention (CDC). The Center will apply for this funding and launch a new program called the Maryland Heart Health Program (the Program). The Program will provide resources to strengthen MDH’s efforts to reduce the burden of cardiovascular disease (CVD) and build on the accomplishments and outcomes of the Center’s previous heart disease grant that addressed healthcare system changes and community-clinical linkages. The purpose of the Program is to support investments in implementing and evaluating evidence-based and evidence-informed strategies to prevent and manage CVD. CVD is the leading cause of death in Maryland, and cerebrovascular diseases are the fourth leading cause of death.1 Disparities in CVD mortality exist among demographic categories such as race, with non-Hispanic blacks having a mortality rate that is 120% higher than non-Hispanic whites and 260% higher than Hispanics.2 These racial disparities also exist in the mortality rates for cerebrovascular diseases with non-Hispanic blacks have a significantly higher mortality rate compared to non-Hispanic whites. The Center plans to partner with organizations in high-risk communities to address the needs of priority populations. The Center will utilize an existing heart disease advisory group to support a Learning Collaborative (LC) to support health agencies to facilitate communication and exchange of ideas and leverage technical and financial resources to support improving cardiovascular health outcomes for all Marylanders, specifically focusing on those with or at the highest risk of poor cardiovascular health outcomes. The LC will have expertise in addressing hypertension and high cholesterol with populations experiencing health inequities and disparities. The Program will expand the work of the Maryland Primary Care Program (MDPCP) and the Mid-Atlantic Association of Community Health Centers (MACHC) to increase the use of standardized processes or tools, multidisciplinary care teams, and engagement of CHWs within primary care settings. Both will increase access and track supportive services for those at the highest risk of poor cardiovascular health outcomes. MDPCP supports building a robust, effective primary care system, including medical, behavioral, and social needs in 525 practices with 374,000 patients. MACHC’s 14 Maryland centers are nonprofit, community-directed providers that serve as the health home for over 338,000 low-income people. Additional strategy activities include expanding the number of self-measured blood pressure programs (SMBP) with clinical support among populations with the highest hypertension. MDH will add two new Healthy Heart Ambassador sites and two new SMPB initiatives in food delivery programs. Outcomes to be addressed during the five years of this grant are: Outcome Measure 1: Increase the use of EHR/ HIT to report, monitor, and track clinical and social services and support needs data to improve the detection of healthcare disparities and the identification, management, and treatment of patients at the highest risk of CVD, with a focus on hypertension and high cholesterol. Outcome Measure 2: Increase utilization of standardized processes or tools in FQHCs and MDPCP practices to identify, assess, track, and address the social services and support needs of patient populations at the highest risk of CVD. Outcome Measure 3: Increase the use of multidisciplinary care teams in federally qualified health centers (FQHCs) and in Maryland Primary Care Program (MDPCP) adhering to evidence-based guidelines to address patients' social services and support needs and improve