Thursday, September 19, 2024
9/19/2024
Although Minnesota has had the lowest heart disease death rate in the nation since at least 1999, this low rate hides glaring disparities in deaths, hospitalizations, risk factors, and more. Many communities experience systemic barriers that lead to higher disease burden and associated health data disparities, notably among Black, Indigenous, and communities of color. The 2304 grant will enable MDH to build on the past years of success in increasing awareness, education, and support for hypertension and high cholesterol identification and management. Expanding our approach to be inclusive of screening for social determinants of health (SDoH) and enhancing referrals to services and programs designed to meet diverse and changing social needs is a natural progression for this collective work. In collaboration with other CDC-funded chronic disease programs at MDH, these activities will be rooted in a whole person view of health, designed to support a culture of health that is inclusive of community assets and responsive to social support needs. Activities to support these goals will focus on effective implementation of health information technology, increasing and expanding team-based care approaches within clinical settings, screening for SDoH, and enhancing referral networks to ensure that social supports to meet basic needs are in place and being used. 2304 work will be guided by a learning collaborative (LC) that will use a community engaged approach to co-identify barriers to positive health outcomes and opportunities to co-create solutions to be tested and evaluated for impact. These strategic interventions are planned in partnership with health systems, community organizations, and strategic partners from multiple sectors. MDH will support the implementation and evaluation of a set of evidence-based and evidence-informed strategies. Our approach is rooted in Minnesota's Action Plan to Address Diabetes, Cardiovascular Disease, and Stroke 2035, our new state plan designed through a multi-year public engagement process, and the guidance of a Leadership Team representing community, public health, medicine, and academia. The long-term outcomes for this proposal are to 1) improve cardiovascular health; and 2) reduce disparities in cardiovascular health. The short-term outcomes include: 1) increased use of electronic health records (EHR)/health information technology (HIT) to report, monitor, track clinical/social needs data to identify, manage, and treat patients at highest risk of CVD ; 2) increased use of standardized processes/tools to identify assess, track, and address social needs of patients at highest risk of CVD; 3) increased use of EHR/HIT to communicate and coordinate across care team members; 4) increased use of multidisciplinary care teams adhering to evidence-based guidelines to address patients’ social needs; 5) increased multidisciplinary partnerships that address barriers to social needs; 6) increased community clinical links to identify and respond to social needs; 7) increased use of community health workers to provide continuum of care extending clinical interventions and addressing social needs; and 8) increased use of SMBP with clinical support in clinic or community.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).
