Heart Disease: Innovative National Cardiovascular Programs

The Brown County Heart Health Learning Collaborative (BCHHLC) is co-led by CDPP and Wello.

Wello is a community-based organization with a mission to co-create fair community conditions to drive high levels of health and well-being for all residents. Their efforts focus on engaging the community to identify and address challenges in health care and social service delivery and infrastructure in Brown County. A local leadership team of resource center partners: Casa ALBA Melanie, We All Rise, and COMSA, continues to expand the collaborative to include a wide variety of community and clinically based organizations.

Prevea Health serves as a key clinical partner. Collaborative members strive to improve community access to cardiovascular prevention and management resources.

Contact Beth Heller at beth@wello.org to learn more.

The CDPP and Rural Wisconsin Health Cooperative (RWHC) partner in a learning collaborative focused on improving geographic variation in health outcomes. This network of 44 rural health systems located throughout Wisconsin take action to prevent risk factors for cardiovascular disease while promoting environments that foster good health in rural communities. RWHC provides hands-on technical assistance, coordinates quality improvement projects, and facilitates peer sharing to advance team-based care and address health-related social needs at participating rural health systems:

Wisconsin Association of Free and Charitable Clinics (WAFCC) Collaborative provides state advocacy, educational opportunities, consulting and telehealth services to Wisconsin’s free and charitable clinics. WAFCC fosters sustainability through collaboration, networking, and resource sharing among new and existing free and charitable clinics. As part of the collaborative, five free and charitable clinics are implementing quality initiatives focused on both clinical and social service interventions to improve cardiovascular disease prevention and treatment services.

Partners include:

Pharmacy Society of Wisconsin (PSW) is a membership organization, providing education and practice advancement opportunities for over 4,000 pharmacist, pharmacy technician, and student members.

As a contracted partner for both the National Cardiovascular Health Program and the Innovative Cardiovascular Health Program, PSW supports triads consisting of pharmacies, community-based organizations, and primary care providers to coordinate chronic care management and address social needs. This effort includes strategies to provide ongoing education and support around non-medical barriers to health, such as transportation and food security. Integrating social needs assessments and best practices into patient encounters is an important approach. Collaborative practice agreements between the pharmacists and primary care providers improves care coordination and management. Increasing connection to self-measured blood pressure programs help patients monitor and control their condition.

Partners include:

• Brown County: Streu’s Pharmacy Bay Natural, Casa ALBA Melanie, and NEW Community Clinic.
• Dane County: Meadowood Health Partnership and Access Community Health Center.
• Oneida County: Rhinelander Hometown Pharmacy and the Aging and Disability Resource Center of Oneida County.
• Marathon County: Wausau Family Pharmacy, The Hmong and Hispanic Communication Network (H2N), and Dr. Kevin Thao.
• Milwaukee County: Hayat Pharmacy and Parent University

The Milwaukee Heart Health Learning Collaborative (MHHLC), the state’s Innovative Cardiovascular Health Program, is co-led by CDPP, Health Connections, Inc., and Y-EAT Right, Nutritional Consultant for Healthy Living. Contracted partners include IMPACT Connect, City on a Hill, and Pharmacy Society of Wisconsin (PSW).

MHHLC convenes partners monthly to achieve the goals of work groups focused on community engagement, data and quality improvement, and community-clinical linkages. These work groups allow members to align efforts while working in their areas of expertise. In addition to these monthly meetings, there are community conversations and a Community Member Advisory Council to educate those within the catchment area on cardiovascular disease and ensure that projects implemented meet the needs of the community.

The Innovative Cardiovascular Health Program (23-0005) addresses the needs of residents in a census tract with a hypertension prevalence of 53% or greater. Census Tract 1860 and adjacent neighborhoods in Milwaukee, meet this threshold. The high prevalence of hypertension and barriers to accessing care allow the program to address three zip codes 53205, 53212, and 53206 and 17 high-need neighborhoods:

Contact the MHHLC co-directors, Ericka Sinclair at esinclair@hcmke.org or Dr. Yvonne Greer and yeatright.57@gmail.com with questions or information about the MHHLC.

Many health systems use electronic health records and health information technology to measure and track clinical quality measures.

As part of our effort to improve cardiovascular health across the state, we promote the adoption of standardized clinical quality measures to prevent and manage heart disease and related conditions, like high blood pressure and cholesterol. These measures help to improve monitoring of health and health care disparities among populations and inform activities to eliminate them.

Read Guidance for Tracking and Monitoring Key Clinical Measures for Groups with Hypertension and High Cholesterol, P-03703 (PDF), to learn about recommendations for pulling and utilizing this data and implementing quality improvement initiatives to improve hypertension (HTN) and high blood cholesterol (HBC).

Self-measured blood pressure (SMBP) monitoring involves an individual's regular use of personal blood pressure monitoring devices to assess and record blood pressure across different points in time outside of a clinical setting. There is strong evidence that SMBP monitoring with clinical support helps people with hypertension lower their blood pressure. Clinical support should occur before, during, and after a health care appointment, and may include instructing clients on how to measure their blood pressure with a home device, helping individuals with medication access and management, leading their own care, and emotional management. Services should consider individuals' perspectives and be tailored to their needs.

Resources

• Along with the American Heart Association, we promote the use of Check. Change. Control., an evidence-based hypertension management program that utilizes self-measured blood pressure monitoring to empower patients in ownership of their cardiovascular health.
• The Chronic Disease Prevention Program created Self-Measured Blood Pressure Tool for Wisconsin Health Systems and Clinics, P-03163 (PDF) to help clinics implement a SMBP program for their patients.
• The National Association of Community Health Centers (NACHC) created a Self-Measured Blood Pressure Monitoring (SMBP) Implementation Toolkit to help organizations implement SMBP successfully into their care processes and workflows. The toolkit will help organizations:
  • Determine goals and priority populations.
  • Align SMBP patient training to their practice environment.
  • Consider SMBP tasks by staff roles.
  • Review key features and functionalities for choosing a SMBP data management software solution or technology partner.
  • Develop an SMBP implementation protocol.

Team-based care (TBC) enhances patient care with health care providers working collaboratively.

While treating the patient a multidisciplinary team may:

• Provide education.
• Identify risk factors.
• Prescribe and modify treatments.
• Facilitate two-way communication with the patient.

Evidence shows that team-based care leads to improved high blood pressure control and better medication compliance.

Medication therapy management

Medication therapy management (MTM) is a distinct service to ensure the best therapeutic outcomes for patients. MTM has been shown to lower blood pressure, cholesterol, and improve medication adherence. It includes five core elements:

• Medication therapy review
• Personal medication record
• Medication-related action plan
• Intervention or referral
• Documentation and follow-up

In Wisconsin, MTM is a covered benefit for Medicaid-eligible members. Eligible members receive a comprehensive medical review/assessment (CMR/A). We work closely with the Pharmacy Society of Wisconsin (PSW) and their Wisconsin Pharmacy Quality Collaborative (WPQC) program to engage pharmacists in the promotion of MTM and lifestyle modification. The PSW provides professional training, toolkits, and technical assistance to 250+ accredited pharmacies and nearly 500 certified pharmacists across Wisconsin.

Resources

• Wisconsin Nurses Association created a model of care to drive health care transformation that moves toward value-based care, better patient health and safety, and improved population health.
• The Chronic Disease Prevention Program created Team-Based Care Tool for Wisconsin Health Systems and Clinics, P-03162 (PDF) to help health systems assess their current practices and identify opportunities to improve.
• CDC Million Hearts® Evidence-based Hypertension Treatment Protocols: Simple, evidence-based protocols can have a powerful impact on hypertension control.
• Hypertension Control: Change Package for Clinicians: A quality improvement tool for ambulatory clinics. (PDF)
• Measure Up Pressure Down^TM: Provider Toolkit to Improve Hypertension Control (PDF): Useful tools, tips, and resources to jump-start hypertension quality improvement initiatives.
• Improving Chronic Conditions, Hypertension & Diabetes: Care & Outcomes: Wisconsin Collaborative for Healthcare Quality (registration required to download)
• MyHEART: Information & Resources for Young Adults with Hypertension: Resource developed by Dr. Heather Johnson from the University of Wisconsin-Madison to address the unmet need of educating young adults on hypertension.

Social Determinants of Health (SDoH), defined by the CDC (Centers for Disease Control and Prevention) are non-medical factors that affect health outcomes. They include the conditions in which people are born, grow, work, live, and age. SDoH also include the broader forces and systems that shape everyday life conditions.

Screening for SDoH

Screening for SDoHs helps providers understand patients' needs better so they can treat and refer them to appropriate services or supports. As of January 1, 2024, the CMS (Centers for Medicare and Medicaid Services) require health care organizations to screen for five SDoH:

• Food insecurity
• Interpersonal safety
• Housing insecurity
• Transportation insecurity
• Utilities

Resources

• Social Determinants of Health (SDOH) | About CDC
• Agency for Healthcare Research and Quality has tools to help health care organizations address SDoH.

Community health workers (CHW) are an important part of Wisconsin's public health and health care systems. They are the bridge that connect people to care and resources to help them be healthy. CHWs are community members with lived experience in overcoming barriers to access, navigating systems, and using resources in the communities they serve. The primary goal of a CHW is to improve health outcomes of people in their communities.

CHWs can be found working in many different places, like health departments, community organizations, hospitals, clinics, and schools. CHWs work under different job titles, including promotores(as) de salud, community health representatives, doulas, neighborhood navigators, patient navigators, and peer educators.

CHW and heart health

The CDPP promotes the importance and impacts that CHWs have on improving heart health conditions among community members and families across Wisconsin. The following strategies highlight CHWs and heart health promotion throughout the National and Innovative Cardiovascular Disease funding:

• Ensuring CHWs have equitable and appropriate access to electronic health records and documentation databases
• Integrating CHWs as part of multi-sector care teams
• Working with CHWs to address social service needs and improving community-clinical linkages related to hypertension and cholesterol
• Supporting CHW workforce development through training, professional development, and professional networks
• Supporting CHW workforce sustainability through advancing CHW leadership, authentic CHW allyship, and financial sustainability

Resources

• For additional resources and to learn more about other ways to support CHW work in Wisconsin, visit the Community Health Worker Webpage
• Envision Equity—CHW training and technical assistance center