ACHIEVE P3 - CHD

ABSTRACT The substantial improvement in lifespan and health span in the United States, attributable to improvements in awareness, detection and treatment of risk factors have not translated into Black individuals. Life expectancy among Black males remains recalcitrantly low and comparable to the developing world. Socio-economic status, education, neighborhood, built environment, community context and behavioral factors or social determinants of health (SDoH) account for ~80% of variance in health outcomes and cluster geographically. Strategies to address health inequities in Black individuals must acknowledge and address SDoH. Precision health technologies, access to care coordination and guidance on lifestyle, diet and pharmacotherapy have traditionally been the prerogative of the privileged, but offer value, by virtue of their accuracy and co-benefits of engagement, education and empowerment. The overall hypothesis of PROJECT 3 is that a visionary free precision medicine approach to identify “at-risk” Blacks. and linkage to care using a pragmatic reimbursable HUB-facilitated, community health worker (CHW) led, personalized, adaptable approach to lifestyle and life circumstance (PAL2) intervention, will improve the triple goal of optimal blood pressure, lipids and glucose targets. PAL2 will incorporate proven interventions including CHW care coordination, motivational interviewing, lifestyle coaching, home blood pressure monitoring and importantly will be tunable to address high risk patients (CAC≥100) with a nurse-dietician-pharmacist. We will partner with the Cuyahoga Metropolitan Housing Authority (CMHA), one of the nation’s largest subsidized housing programs and Better Health Partnerships (BHP), a Cleveland based non-profit, that offers a CHW-HUB model of care. Utilizing a Practical Robust Implementation and Sustainability Model (PRISM) framework to address RE-AIM domains (Reach x Efficacy: Adoption, Implementation, Maintenance) and contextual factors, our multi-disciplinary team will test the benefits of a tunable PAL2 intervention to achieve guideline driven targets while exploring contextual factors that may determine the success of our intervention.