Vermont’s populations that are disproportionately affected by chronic disease, include those with multiple chronic conditions, a disability, lower levels of education and income, and those who are over 65 years. Hypertension (HTN) is significantly more likely among adults with any disability (37% vs. 22%), with poor mental health 30% vs. 24%), among those living at a low or middle SES compared to a high SES (33% and 27%, vs 21%, respectively), and among those living in a small rural town compared to an urban one (27% vs 22%) (BRFSS 2021).
The Vermont Department of Health (VDH) will leverage its community-clinical health delivery system that is based on a statewide Patient Centered Medical Home (PCMH) and Community Health Team model. All Health Service Areas (HSAs) have a multi-discipline and cross-sector Accountable Community for Health (ACH), which mirror the Learning Collaborative requirement in this NOFO and will be considered as such. Vermont will engage with the statewide network of Federally Qualified Health Centers (FQHCs), VDH Offices of Local Health (OLH), the ACH networks, the VT Blueprint for Health, Medicaid, and OneCare VT (ACO), and our statewide network of Community Health Workers (CHWs). We have selected three priority HSAs to work with, whose BRFSS data demonstrate a higher burden of hypertension, cholesterol, and/or cardiovascular disease. These are Rutland, Newport/ St. Johnsbury, and Franklin / Grand Ilse. In Franklin Grand Isle, we will work with an Abenaki Nation indigenous tribe. These partnerships will promote and facilitate access to services that target Social Determinants of Health (SDoH) needs, Self-measured Blood Pressure (SMBP) supports, and referrals to MyHealthyVT programming, including the Health Coaches for Hypertension program at no cost to eligible Vermonters and priority populations.
Vermont expects to achieve the following outcomes by the end of the project period: i) increased capability by the statewide Federally Qualified Health Centers and Support and Services at Home sites to collect and track SDoH data; ii) increased number of CHWs trained in HTN and cholesterol management; iii) increased participation in the Health Coaches for HTN self-management program across Vermont; iv) improvement in HTN control and cholesterol screening rates in the target regions; and v) increased HTN incidence in FQHC practices in the target HSAs.
All of our sub-contractor partners will serve priority populations and/or high-burden regions and the proposed activities will focus on projects including, but not limited to Strategy One: the statewide capacity to collect and track SDoH data at VT FQHCs; development of an SDoH scorecard at statewide senior housing facilities; increased EHR capacity to capture SDoH data; and focused SDoH projects across VT. Strategy Two: supporting team-based care through enhanced HTN protocols that include SDoH; statewide FQHC and PCMH technical assistance for team-based care approaches; and SDoH screening pilots with CHW supports; and Strategy Three: Continued expansion of statewide CHW infrastructure; CHW HTN module development; Medicaid SMBP initiative; and SMBP projects in targeted regions.
VDH’s comprehensive staff, partner, and business infrastructure will support all projects, which has proven successful across many CDC Cooperative Agreements.
