The Center For Disease Control and Prevention National Cardiovascular Health Program aims to implement and evaluate evidence-based strategies contributing to the prevention and management of cardiovas - The WV Department of Health and Human Resources, Bureau for Public Health (WV DHHR BPH), Division of Health Promotion and Chronic Disease Prevention (HPCD) submits this funding application for CDC-RFA-DP-23-0004, The National Cardiovascular Health Program. As the second-most rural state in the nation, West Virginia (WV) is the only state located entirely within the Appalachian region, an area distinguished by mountainous terrain, geographic isolation, and historical economic hardship and exploitation. The COVID-19 pandemic greatly emphasized the disparities suffered by many in rural WV, further stressed by the lack of access to healthcare, broadband internet, and transportation. Those with intersecting identities, such as racial and ethnic minorities, LGBTQIA+ individuals, etc., in rural areas continue to experience the most significant health disparities in access to care, incidence, prevalence, mortality, and burden of chronic disease. Through this application, HPCD seeks to build upon the accomplishments and outcomes achieved in DP1815 Improving the Health of Americans Through Prevention and Management of Diabetes, and Heart Disease and Stroke, as well as leverage new and existing partnerships to expand WV’s existing “Synergy Partners”, thus creating a broader learning collaborative. Under CDC grants DP1815 and DP1305 State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors, and Promote School Health, HPCD established state-wide partnerships that increased the use of, and adherence to, evidence-based guidelines and policies related to team-based care, systematic referrals, self-management, and participation in evidence-based lifestyle change interventions for individuals with cardiovascular disease (CVD). These Synergy Partners work with HPCD in a mutually supportive capacity to achieve meaningful change, and include small, grassroots Community-based Organizations (CBO), as well as larger, statewide organizations and institutions of higher learning. HPCD will work with partners throughout the state to identify and remove barriers to care by addressing the Social Determinants of Health (SDOH) and will work with partners to target populations that have systematically experienced a greater burden of disease due to historical discrimination or exclusion. At the conclusion of this grant, HPCD will have tracked and monitored clinical and social services and support needs measures shown to improve health, wellness, and health care quality. HPCD will have identified patients at the highest risk of CVD with a focus on hypertension and high cholesterol. HPCD will have increased the use of electronic health records (EHR) and health information technology (HIT) to report, monitor, and track clinical and social services and support needs. HPCD will also have increased multidisciplinary partnerships that address the social services and support needs of patient populations at highest risk of CVD. At the end of Year 5, HPCD will have strengthened community clinical linkages within communities and WV’s health systems. HPCD will have also increased engagement of community health workers (CHW) and increased the use of self-monitored blood pressure (SMBP) programming with clinical support within populations at highest risk of hypertension. HPCD will share findings and trends from data collection with CBOs and partners for ongoing learning and quality improvement
