The Pennsylvania Department of Health (DOH) will implement and evaluate a comprehensive, evidence-based, and evidence informed cardiovascular disease (CVD) prevention and management program to improve cardiovascular health and reduce inequities and health care disparities in high-risk priority populations across the Commonwealth.
Throughout the project period, the DOH will improve blood pressure control and reduce blood pressure disparities among targeted populations within partner healthcare and community settings; and increase utilization of and mitigate social support barriers among priority populations at highest risk of CVD, with a focus on hypertension and high cholesterol.
These outcomes will be accomplished through increased use of Electronic Health Records (EHRs) or Health Information Technology (HIT) to report, monitor, and track detection of health care disparities, support communication and coordination among multidisciplinary care team members, and identify, manage, and treat patients at the highest risk of CVD with emphasis on hypertension and cholesterol management. The DOH will address identified barriers to social services and support needs within populations at highest risk of CVD with the assistance of the CVD learning collaborative (LC) as well as promote increased use of multidisciplinary teams and adherence to evidence-based guidelines. The DOH will increase engagement of Community Health Workers (CHWs) to provide care beyond standard clinical interventions and increase community-clinical links to identify, respond to, and address social services and support needs of populations at highest risk of CVD.
All activities and progress toward identified outcomes will be measured, tracked, and analyzed through data collection led by the University of Pittsburgh Evaluation Institute for Public Health (EI). All data analyses will provide feedback pertaining to successes, identify shortcomings, and provide ongoing quality improvement resulting in high-quality health care outcomes.
The goals of these coordinated efforts, through the development of a comprehensive CVD program and LC, will be to achieve a long-term increase in the number of adults aged 18-85 with hypertension and high cholesterol that have achieved control; reduce health care disparities in CVD among high-risk populations and communities disproportionately affected by CVD; achieve optimal health outcomes for priority populations by assessing Social Determinants of Health (SDOH) and responding to those social needs; and by using specific evidence-based strategies to advance health equity goals.
