Metrohealth System, the

Heart Health Equity in Cuyahoga County Communities - Ohio Is in the Top 25% of States for Heart Disease Events and Deaths in the United States. Cuyahoga County Which Is Where Cleveland, Ohio Is Located, Has High Rates of Heart Disease Risk Factors and Contains Half of the Communities in Ohio With a High Blood Pressure (BP) Prevalence > 53%. the People Living in These 15 Urban Communities Are Primarily Black and Low-income. Our Purpose Is to Improve Heart Disease Health Equity by Applying a Learning Collaborative Quality Improvement (QI) Approach With Data Sharing Among Cleveland Area Health Systems, Community Organizations, Insurance Companies, and Other Partners to Align Efforts for Greater Heart Health Impact Within the Identified Census Tracts. Our Qi Project Focuses on the 3 Strategies in the Funding Announcement: 1) Population Health Approaches, Including Use of Geographical Mapping Tools With Customized Outreach and Engagement of Patients Seen in Selected Communities; 2) Team-based Care to Improve High BP and High Cholesterol, Including Building Multidisciplinary Partnerships; and 3) Linking Clinics and Community Partners to Better Address Health Related Social Needs and Promote Use of Self-measured BP. We Will Use a Previously Successful Approach to Carry Out the 3 Strategies: 1) Qi Coaching of Health System and Community Partners; 2) Data for Audit and Feedback for Continuous Qi and to Identify Best Practices for Sharing; and 3) Annual Learning Collaboratives and Quarterly Webinars for Educational Clinical and Qi Content, and Peer-to-peer Learning. Key Innovative Areas Include: 1) a Comparison of the Unite Us Electronic Online Platform and Community Health Worker (CHW) Pathways Hub Model for Addressing Health-related Social Needs and Heart Health Outcomes; and 2) Implementation and Evaluation of a Chw-led Ymca Self-measured BP Program. a Focus on Improving High BP and High Cholesterol Including Attention to Health-related Social Needs and Structural Racism for People Living in the Identified Communities Could Have a Strong Impact on Heart Health Equity in the Region and Be a Model for Spread Across the State and Nation.