Virginia’s Successful Clinical-Community Care Model to Address Hypertension Set to Expand Across the Commonwealth

February 22, 2018 | ASTHO Staff

This month, ASTHO reached out to Levine to learn how the health department hopes to scale up a successful clinical-community care model for hypertension control in other cities, counties, and healthcare practices across the Commonwealth.

What activities are underway at the Virginia Department of Health to recognize American Heart Month?

Heart disease is one of the leading causes of death faced by Virginians with 33.2 percent of residents reporting high blood pressure, ranking Virginia 34th in the nation for high blood pressure prevalence.

Of significant note this year is our ongoing collaborative, the Virginia Cardiovascular Health Collaborative (VCHC), to promote blood pressure self-management and hypertension control. With support from an ASTHO grant opportunity, VDH conceptualized a dual-approach initiative: a clinical care model between Anthem Blue Cross and Blue Shield and Commonwealth Primary Care, and a community care model between Anthem HealthKeepers Plus and Fairfield Court, a housing development community. Crucial to success of the program is the commitment of the Richmond City Health District, where staff have implemented both models by utilizing community health workers (CHWs) to achieve the Triple Aim of improved health outcomes, reduced healthcare costs, and increased patient satisfaction. The VCHC has a primary focus on improving hypertension control and addressing socioeconomic barriers, including transportation and financial needs.

At the Virginia Department of Health (VDH), we strive to find innovative approaches to make Virginia the healthiest state in the nation. One such approach has been ongoing for the past several years; during that time over 200 congregations have enrolled in Virginia Congregations for Million Hearts, a statewide initiative to enlist the support of faith-based organizations in raising awareness and preventing cardiovascular disease with a focus on hypertension control. VDH communications staff have been promoting American Heart Month and Go Red for Women across social media platforms. VDH staff also participated in the Richmond Women’s Health and Fitness Expo to share information on heart health, healthy eating, and exercise resources.

How are you integrating hypertension control into chronic disease efforts and other public health programs?

With a focus on hypertension control, the VCHC follows a population health method of identifying patients with hypertension and providing additional supports based on their health and non-health needs. The process begins when Anthem Blue Cross and Blue Shield and Anthem Healthkeepers Plus identify members with blood pressure readings >140 systolic and/or >90 diastolic who are patients of Commonwealth Primary Care or residents of Fairfield Court. Hired CHWs receive the list of patients and set an initial in-person meeting at the clinic or community resource center. Within the first meeting, participating patients complete a hypertension care plan, discuss health and non-health needs, receive a blood pressure monitor, and guidance on how to measure and track their blood pressure at home. The CHW maintains contact with the patient via in-person meetings, phone calls, texts and emails resulting in referral of patients to appropriate clinical and community resources. The CHW’s peer support strengthens patient knowledge and commitment to taking prescribed medications, maintaining a healthy diet, and incorporating exercise into daily habits.

With health equity as a focus for VDH, how has your work been successful in addressing the nexus between social determinants and cardiovascular health?

CHWs are critical to addressing health equity in the VCHC. Pairing patients with a CHW allows healthcare providers the opportunity to address health equity at the individual level. Whether an extension of a healthcare service or a standalone operation, leveraging CHWs has already shown improved health outcomes in the VCHC.

VDH has also started discussions to determine how Moving to Institutional Equity can be used within the agency and beyond to ensure equity is embedded in all policies and practices. The tool, developed and released by the National Association of Chronic Disease Directors, primarily focuses on racial inequities, but the guiding principles can be applied across other inequities to ensure individuals receive equitable care.

What do you feel are some of the biggest systems-level changes or outcomes associated with the VDH Million Hearts initiative?

To date, Commonwealth Primary Care has embedded CHWs in one clinic. With a total patient panel size of 100,000 and seven clinic sites spread across the Richmond metro area, they have now fully embraced the concept of CHWs and are ready to expand the CHW initiative to the remaining clinics. We anticipate that other health systems and organizations across the Commonwealth will realize the benefit of engaging and embedding CHWs within their organizations following Commonwealth Primary Care’s success.

What’s next for Virginia, in terms of growing or sustaining the momentum around hypertension and blood pressure control? How do you hope to achieve this?

Sustainability has been achieved with Commonwealth Primary Care investing in hiring CHWs after the pilot program ends. VDH will scale this model for hypertension control in other cities, counties, and healthcare practices. Beginning with Commonwealth Primary Care and Richmond City Health District/Fairfield Court, the network for best practices and lessons learned expands as other healthcare practices and community entities participate in this unique approach to hypertension control. Growing and sustaining the momentum around hypertension control and becoming the healthiest state in the nation cannot be achieved by one entity alone. It requires interdisciplinary collaboration to achieve the collective impact and healthier society in which we live, work, eat, play, and worship.