Socioeconomic inequality and other adverse social determinants of health have long contributed to poor health outcomes particularly in Non-Hispanic Black (NHB) populations in low-income areas of the South. Tennessee (TN) ranks 3rd in the nation in cardiovascular disease (CVD) event rates, 7th in prevalence of hypertension (HTN), 6th in heart disease mortality, and 5th in stroke mortality and the burden of CVD health inequities is greatest in the TN census tracts targeted by this Program. High rates of premature death and disability in these vulnerable communities are particularly driven by cardiovascular deaths from stroke and heart attack largely caused by high rates of HTN in these communities, which are in turn caused by high rates of obesity and poor access to primary care. For TN to effectively reduce its high rates of CVD and CVD disparities it must focus intensively on the essential social service and primary health care needs of the predominantly NHB populations living in its highest need neighborhoods. Thus, the Tennessee Heart Health Network (TN-HHN) Innovative Cardiovascular Disease Program will work to improve heart health in TN with an intensive focus on adults aged 18 and older with a HTN crude prevalence of 53% or higher (population of focus), as shown by data specifically at the census tract level. Action focused on these highest need census tracts to improve heart health in TN is critical to national efforts to reduce or eliminate disparities in CVD health outcomes and meet Healthy People 2030 goals.
Through the Program, Learning Collaborative (LC) members will work together to understand, implement, and disseminate innovative, evidence-based, and patient-centered approaches to improve cardiovascular health and better support the population of focus. The Program will build on an existing statewide multi-stakeholder heart disease and stroke LC, the TN-HHN, by enhancing its membership to include social service and other community-based organizations, and patient representatives from the communities served. The TN-HHN LC will promote and disseminate evidence-based approaches to address social determinants underlying adverse cardiovascular outcomes and disparities. The Program will focus on collaborating with community health centers serving targeted census tracts with high prevalence of HTN to implement ABCS, with priority on controlling HTN.
Working intensively with the LC participants serving the targeted communities, the LC will focus on implementing on 3 major strategies: 1) Tracking and monitoring clinical measures shown to improve health and wellness and, health care quality within approved populations of focus, and identify patients with hypertension and high cholesterol, 2) Implementing team-based care to prevent detect, control, and manage hypertension and high cholesterol within approved populations of focus, and 3) Assembling or creating multidisciplinary teams to identify patients’ social services and support needs within approved populations of focus.
Through these targeted interventions, the Program will measurably improve short-term performance outcomes related to each strategy; within two to four years will improve intermediate clinical outcomes including blood pressure control, disparities in blood pressure control, and utilization of social support services; and within five years will measurably reduce strokes, heart attacks, and cardiovascular events and decrease disparities within approved populations of focus. Thus, the Program will positively impact racial disparities in stroke, heart attacks, and cardiovascular events related to uncontrolled HTN and high cholesterol through innovative patient-centered equity-focused health system interventions designed to prevent, detect, control, and manage HTN and high cholesterol, intensively targeting TN’s neighborhoods in greatest need.