Cardiovascular Health Innovation Program - The California Department of Public Health (CDPH) is a state health department applying for the Centers for Disease Control and Prevention funding opportunity, CDC-RFA-DP23-0005, National Center for Chronic Disease Prevention and Health Promotion, The Innovative Cardiovascular Health Program. This funding will support public health efforts in prevention and management to improve the health and quality of life for Californians ages 18 years and older, residents of Riverside County, including census tracts with a prevalence of hypertension (HTN) >53%, a diagnosis of cardiovascular disease, and high blood cholesterol (HBC). CDPH and Riverside County Department of Public Health (RDPH) will integrate and implement health equity programs to address the needs of underserved populations that are disproportionately affected, uninsured, and underinsured with or at risk of HTN and HBC. The proposed priority population will also include non-Hispanic Black/African American, Asian American, American Indian or Alaska Native, and Hispanic communities. Program strategies include tracking and monitoring clinical and social services and support needs (e.g., food insecurity, language assistance, and transportation), implementing team-based care, and linking community resources and clinical services to prevent and manage HTN and HBC. CDPH will implement these strategies in Riverside County with a focus on census tracts with HTN >53%. CDPH will work with RDPH, which represents an integration of systems that consist of Riverside University Health System (RUHS) medical center, 13 community health centers, pharmacies, public health, and behavioral health along with existing partnerships with health plans, and county programs such as the Office of Aging and the Department of Social Services. RDPH has electronic health record systems that will be optimized to access community resources and foster sustainability, reducing disparities in blood pressure control and high blood cholesterol levels, and increasing the use of social services or support needs among populations at highest risk for cardiovascular disease. CDPH and RDPH will collaborate with other state agencies, learning collaboratives, health systems, and partners, including Riverside County Health Coalition, to focus on health equity and Social Determinants of Health, which will result in better health outcomes. CDPH and RDPH will assess, monitor, and analyze innovative interventions using high quality performance measures.