Health Research, Inc.

The Innovative Cardiovascular Health Program - Through Health Research, Inc., the New York State Department of Health (NYSDOH) Requests Funding to Build Upon Successes to Implement and Evaluate Evidence-based Strategies to Prevent, Detect, Control, and Manage Hypertension (HTN) and High Cholesterol (HC) While Reducing Disparities in Cardiovascular Health (CVH). Nysdoh, in Collaboration With Healthelink and the Community Health Care Association of Nys (chcanys), Will Recruit Federally Qualified Health Centers (FQHCS) Serving Census Tract 33.02 on the East Side of Buffalo in Erie County With a HTN Prevalence of 54.1% to Implement and Evaluate These Strategies 1) Create a Learning Collaborative That Will Serve as a Hub, Focused on Developing Approaches to Improving CVH and Mitigate Social Determinants of Health in the East Buffalo Community 2) Increase the Use of Electronic Health Records (EHRS) and Health Information Technology to Identify, Track, and Monitor HTN, HC, and Social Services and Support Needs (SSSNS) Measures; 3) Support Multidisciplinary Teams to Use HTN and HC Registries to Identify and Address Disparities in Control and Management; and Screen and Identify Patients Sssns and Refer to Social Support Services; 4) Create Community-clinical Linkages That Support Bidirectional E-referrals That Address Barriers Patients Experience Accessing Social Care Services and That Improve HTN Outcomes and Reduce Disparities in CVH. Outcomes: Nysdoh Will Make Measurable Improvements in the Following Intermediate Outcomes: Improved Blood Pressure Control and Reduce Disparities in Hypertension Control Among Populations Within Partner Health Care and Community Settings and Increase Utilization of Sssns Among Populations at Highest Risk for HTN and HC.