The National Cardiovascular Health Program - The Texas Department of State Health Services (DSHS) is applying for CDC-RFA-DP-23-0004: The National Cardiovascular Health Program. Cardiovascular disease (CVD), specifically heart disease, is the leading cause of death for Texans. In 2021, heart disease and overall CVD made up almost one-fifth (18.8 percent) and one-fourth (25.2 percent) of deaths in Texas, respectively. CVD age-adjusted mortality rate showed a significant increase from 224.3 per 100,000 people in 2016 to 241.7 per 100,000 people in 2021. An estimated 7.0 percent of adult Texans reported having CVD in 2021. In fiscal year 2021, total Medicaid expenditure for CVD was over $1.9 billion. Non-Hispanic Black (NHB) Texans are disproportionately affected by CVD. Although prevalence of CVD is lower among NHB Texans, mortality and hospitalization rates are higher compared to non-Hispanic White (NHW) Texans. In 2021, age-adjusted mortality rates were significantly higher among NHB at 321.1 per 100,000, compared to NHW Texans at 259.1 per 100,000 people. Using geographic information systems, regional bivariate analysis of high blood pressure and high cholesterol showed that Public Health Regions (PHRs) 4 and 5 have higher estimates of both high blood pressure (43.7 percent and 40.7 percent, respectively) and high cholesterol (47.7 percent and 38.7 percent) compared to other PHRs in Texas. Bivariate regional analyses with high blood pressure hospital discharge data and social vulnerability index show that most counties in PHRs 5 and 8 are considered vulnerable and have high rates of high blood pressure hospitalization. DSHS staff have extensive experience planning, implementing, and evaluating evidence-based, data-driven strategies. The DSHS Heart Disease and Stroke Program (HDSP) has over 10 years of experience in leveraging existing support structures and partnerships who have the expertise, capacity, and experience to ensure activities are culturally appropriate, sustainable, and address the unique needs and strengths of under-resourced communities. Grant activities will address health system interventions to improve the effective delivery and use of clinical and other high-value preventive efforts and community programs linked to clinical services and social supports to improve and sustain management of heart disease. Additionally, the state minority health office (Office of Public Health Policy) is providing an in-kind Health Disparities Policy Analyst that will collaborate with the HDSP to address nonmedical drivers of health for populations at high risk for CVD, including identifying and recruiting appropriate partners for the Learning Collaborative (LC). The LC will support grant activities and concentrate on reducing health disparities for those impacted by a high prevalence of CVD. DSHS will achieve the following outcomes across the five-year funding term: • Increase the use of electronic health records or health information technology and evidence-based guidelines to optimize cardiovascular care and reduce health care disparities for people at highest risk of CVD. • Expand the use of community health workers and multidisciplinary care teams in cardiovascular care and in addressing patients’ social services and support needs. • Increase referrals to and the use of supports for patients in CVD self-management (e.g., lifestyle change programs to control hypertension, self-measured blood pressure monitoring with clinical support, and blood pressure monitor lending libraries). • Expand access, referral to, and use of social services and supports that address non-medical drivers of health in high burden areas for people at highest risk of CVD. • Increase multidisciplinary partnerships at the regional and local levels that address identified barriers to social services and support needs for people at highest risk of CVD. • Improve blood pressure control and reduce disparities in blood pressure control among populations within partner and community settings.