Paul Coverdell National Acute Stroke Program - The Pennsylvania Department of Health (DOH) will implement and evaluate a comprehensive, evidence-based, and evidence informed stroke care and prevention program to improve cardiovascular health and reduce inequities and health care disparities in high-risk priority populations in the targeted region. Throughout the project period, the DOH will improve stroke care through enhanced data collection, strengthen linkages between clinical and community resources for those at highest risk of stroke, and focus on stroke prevention through hypertension detection and control. These outcomes will be accomplished through increased use of Electronic Health Records (EHRs) or Health Information Technology (HIT) to report, monitor, and track detection of health care disparities, support communication and coordination among multidisciplinary care team members, and identify, manage, and treat patients at the highest risk of stroke. This includes those who have experienced a stroke and those with uncontrolled or undiagnosed hypertension. The DOH will address identified barriers to social services and support needs within populations at highest risk of stroke with the assistance of the Paul Coverdell learning collaborative (LC) as well as promote increased use of multidisciplinary teams and adherence to evidence-based guidelines. The DOH will increase engagement of Community Health Workers (CHWs) to provide care beyond standard clinical interventions and increase community-clinical links to identify, respond to, and address social services and support needs of populations at highest risk of stroke. All activities and progress toward identified outcomes will be measured, tracked, and analyzed through data collection led by the Research and Evaluation Group at Public Health Management Corporation (PHMC). All data analyses will provide feedback pertaining to successes, identify shortcomings, and provide ongoing quality improvement resulting in high-quality health care outcomes. The goals of these coordinated efforts, through the development of a Paul Coverdell Acute Stroke program and LC, will be to reduce health care disparities in stroke care among high-risk populations and communities disproportionately affected by stroke; reduce the number of strokes by focusing on hypertension detection and control; achieve optimal health outcomes for priority populations by assessing Social Determinants of Health (SDOH) and responding to those social needs; and the use of specific evidence-based strategies to advance health equity goals.