The Hawaii Department of Health’s (HDOH) Heart Disease and Stroke Program (HDSP), housed in the Chronic Disease Prevention and Health Promotion Division, Chronic Disease Management Branch, has provided statewide leadership and coordination in decreasing the burden of heart disease and stroke. The HDOH is located at 1250 Punchbowl Street, Honolulu, Hawaii 96813. The DOH is applying for CDC-RFA-23-0004, The National Cardiovascular Health Program.
Despite being ranked as one of the healthiest states in the nation, many of the same pressing health trends observed nationally are present in Hawaii, especially among vulnerable populations. Overweight and obesity rates have been increasing over the years, with 33.6% and 24.5% of adults falling into these categories respectively (Behavioral Risk Factor Surveillance System [BRFSS] 2020). Almost a third (30.7%) of Hawaii adults report being diagnosed with high blood pressure (BRFSS 2019), which is a major risk factor for heart disease and stroke. Of those with high blood pressure, 25.6% have not taken any medications to control their condition (BRFSS 2019). Furthermore, 44.1% of Hawaii federally qualified health center patients with hypertension do not have their blood pressure under control (Uniform Data System 2021).
The HDSP will reduce the burden of cardiovascular disease (CVD) among populations disproportionately at risk in Hawaii by developing a Learning Collaborative, improving the tracking and monitoring of patients at highest risk for CVD (e.g., clinical/social services, support, etc.), implementing team-based care to prevent and reduce CVD risk, and linking community resources to address the social determinants of health that impact Native Hawaiians, Other Pacific Islanders, and Filipinos statewide. This will be achieved by using data effectively to target activities, bringing diverse stakeholders together, and collaborating with communities and health care systems to identify realistic and appropriate solutions.
The HDSP expects to achieve the following outcomes:
¿ Increased use of electronic health records (EHRs) or health information technology (HIT) to report, monitor, and track clinical and social services and support needs data to improve detection of health care disparities and the identification, management, and treatment of patients at highest risk of CVD, with a focus on hypertension and high cholesterol.
¿ Increased use of standardized processes or tools to identify, assess, track, and address the social services and support needs of patient populations at highest risk of CVD.
¿ Increased use of EHRs or HIT to support communication and coordination among care team members to monitor and address patients’ hypertension and high cholesterol.
¿ Increased use of multidisciplinary care teams adhering to evidence-based guidelines to address patients' social services and support needs and improve the management and treatment of hypertension and high cholesterol.
¿ Increased multidisciplinary partnerships that address identified barriers to social services and support needs within populations at highest risk of CVD.
¿ Increased community clinical links to identify and respond to social services and support needs of populations at highest risk of CVD with a focus on hypertension and high cholesterol.
¿ Increased engagement of community health workers (or their equivalents) to provide a continuum of care extending clinical interventions and addressing social services and support needs.
¿ Increased use of self-measured blood pressure monitoring with clinical support within populations at highest risk of hypertension.
¿ Improved blood pressure control among populations within partner health care and community settings.
¿ Reduced disparities in hypertension control among populations within partner health care and community settings.
¿ Increased utilization of social services and support among populations at highest risk of CVD, with a focus on hypertension and high choleste