Heart Disease and Stroke Prevention Program

Purpose: To enhance hypertension and high cholesterol prevention initiatives, improve EHR practices, and improve cardiovascular health in underserved communities.

Summary: Grant activities involve conducting in-depth needs assessments to assess health system needs as they relate s to the use of health information systems to collect and use standardized clinical quality measures to track hypertension control measures by race, ethnicity, and language (REaL) and use this data and measures to support team-based care for hypertension and high cholesterol. The assessment results will be used to develop clinic recommendations, workflows, protocols, and/or policies. Similarly, needs assessments will be conducted to assess the health centers’ capacity to adopt and integrate processes or tools to identify, assess, track, and address the social services and support needs. Finally, in collaboration with the American Heart Association (AHA), we will implement the Healthy Heart Ambassador (HHA) program and provide clinical staff trainings based on the AHA/AMA’s Target:BP ™ Measure, Act, Partner (MAP) approach and evidence-based communication strategies.

Associated Projects:

1. Healthy Heart Ambassador (HHA): The HHA is a program composed of evidence-based strategies developed by the Centers for Disease Control and Prevention (CDC) and the YMCA with three focus domains: 1) blood pressure management, 2) identification and control of triggers that impact blood pressure, and 3) adoption of healthier eating habits with clinical support.
2. Target:BP (AHA/AMA): The American Heart Association and the American Medical Association developed the Target:BP ™ initiative. A plan of action that helps healthcare organizations and care teams improve blood pressure control rates, outcomes, and patient quality of care through the implementation of clinical best practices (e.g., treating patients with lower bp target for HTN) and enabling patient self-monitoring blood pressure (SMBP). Target: BP provides healthcare organizations with access to 1) a blood pressure improvement program, 2) SMBP program, 3) blood pressure guideline resources, and 4) tools that can be used to measure and diagnose high blood pressure.

Our aim is to:

1. use the AHA/American Medical Association (AMA)’s Target: BP™ Improvement Program’s evidence-based Measure, Act, Partner (MAP) approach to train all clinical staff in four primary care clinics in PHRs 6/5S on evidence-based communication strategies with patients,
2. use AHA/AMA’s Target:BP™ Improvement Program’s evidence-based MAP approach to training all clinical staff in four primary care clinics on proper blood pressure (BP) measurement procedures.