The Nebraska Department of Health and Human Services is submitting this application in response to CDC-RFA-DP-23-0004 entitled “The National Cardiovascular Health Program.” The Nebraska Department of Health and Human Services will serve the population of Nebraska with a focus on the identified priority populations. This application includes two strategies to track and monitor clinical and social services and support needs measures shown to improve health and wellness, health care quality, and identify patients at the highest risk of cardiovascular disease (CVD) with a focus on hypertension and high cholesterol; three strategies to implement team-based care to prevent and reduce CVD risk with a focus on hypertension and high cholesterol prevention, detection, control, and management through the mitigation of social support barriers to improve outcomes; and three strategies to link community resources and clinical services that support bidirectional referrals, self-management, and lifestyle change to address social determinants that put the priority populations at increased risk for CVD. Statewide and local learning collaboratives will be formed bringing together partners with the knowledge and ability to implement all application strategies, reach priority populations at increased risk for CVD, and achieve the application outcomes.
Expected outcomes include (1) improved blood pressure control among populations within partner health care and community settings; (2) Reduced disparities in blood pressure control among populations within partner health care and community settings; and (3) Increased utilization of social services and support among populations at highest risk of CVD, with a focus on hypertension and high cholesterol. These should lead to two key long-term outcomes: (1) Improved cardiovascular health; and (2) reduced disparities in cardiovascular health. Many of the activities proposed in the application will build on successes and efforts already in progress in Nebraska, utilizing existing partnerships and Department staff with extensive experience in health promotion, chronic disease epidemiology and surveillance, and program evaluation.