Wednesday, April 2, 2025
4/2/2025
The Massachusetts Innovative Cardiovascular Health Program - The Massachusetts Department of Public Health (MDPH) proposes an innovative program to identify, track, and respond to cardiovascular disease (CVD) in adults aged 18 and older living in 24 census tracts with hypertension (HTN) crude prevalence rates of 53% to 70% and receiving care at Caring Health Center (Caring) in Springfield, MA and Dimock Community Health Center (Dimock), in the Roxbury neighborhood of Boston. These two federally qualified health centers provide services in the census tracts and have robust capacity to implement innovative strategies and build strong partnerships with community-based social service and health organizations in their service areas. MDPH will build on its extensive infrastructure, experience, and programming established through previous CDC chronic disease funding to support, promote, and evaluate the three strategies to ensure maximal impact for those with the highest need for CVD interventions. MDPH identified the census tracts using a Geographic Information System (GIS) analysis of data from a large ambulatory care electronic health record data warehouse used for population surveillance called MDPHnet. MDPHnet is the most definitive data source for HTN prevalence at small geographies as it uses medical history and diagnoses and can provide robust measures of disease burden among communities and neighborhoods of color that have faced historical and systemic barriers to participating in traditional surveillance approaches such as telephone surveys. The people who live in the 24 census tracts are majority Black, Indigenous, and people of color, face significant economic hardships, and experience food insecurity. Caring provides services to 19,000 Greater Springfield residents including those who live in the 18 census tracts that have HTN rates of 56% to 70%. Approximately 30% of these Greater Springfield residents have incomes below the federal poverty level; nearly 40% of households receive SNAP benefits; and about 10% of residents are unemployed. Dimock provides care to 17,000 residents of the Roxbury neighborhood of Boston including those who live in the 6 census tracts that have HTN rates of 53% to 70%. In Roxbury, 84% of the residents identify as persons of color; 30% are foreign-born individuals; and 43% live at or under the federal poverty level which is double that of Boston overall (20%) and quadruple that of the state overall (11%). MDPH will work with Caring and Dimock and their two Regional Learning Collaboratives to implement the three strategies in this initiative. MDPH will create data maps using GIS and overlay services to uncover gaps. The Regional LCs will develop a plan for improving services for people living in their census tract areas. To improve CVD in the 24 census tracts, Caring, Dimock, and MDPH with the two Regional Learning Collaboratives and the support of the statewide Massachusetts Heart Disease and Stroke Learning Collaborative will advance the community health worker workforce and support their integration into team-based care; make improvements for detecting and managing CVD, hypertension, cholesterol, and health-related social needs using health information technology and team-based care; and increasing community-clinical linkages to support self-management and lifestyle change and to address health-related social needs. Anticipated outcomes from this initiative include improving the clinical care of patients in the 24 census tracts, increasing the multidisciplinary partnerships that address identified barriers to social services and support needs within populations at highest risk of CVD, and enhancing community services and community clinical linkages to identify and respond to social services and support needs of people at-risk of CVD in the 24 census tracts. The long-term goals are to improve cardiovascular health and reduce CVD disparities in MA.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).