“EvidenceNOW supported by the Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov works to advance heart health in primary care. The project established with seven regional cooperatives is composed of public and private health partnerships and multidisciplinary teams of experts. Each cooperative is recruiting and engaging 250-300 small and medium sized, independent primary care practices.
The EvidenceNOW’s Southwest Cooperative serving Colorado and New Mexico is working to reduce the burden of Cardiovascular Disease (CVD) in Colorado. The Cooperative is helping to provide health information technology assistance to primary practices to help them develop data capacity for quality measures and population management. The plan is to then link the practices with a central data aggregation system for quality measures.
In addition to helping primary practices, Colorado’s Community Health Workers are helping to reduce CVD through a program called CPC Community Health by partnering with health clinics, community-based organizations, and medical centers across the state.
This program is expected to be funded for $200,000 each year from 2015 to 2018 and will provide services to prevent heart problems in four counties in the rural frontier areas in the state. The CHW outreach program was modeled after the Colorado Heart Healthy Solutions (CHHS) program funded by the Colorado Department of Public Health and Environment.
The CHWs operate as a network where workers provide health assessments, education, coaching, referrals to local resources. CHWs provide biometric screening to underserved residents to identify and decrease the risk for CVD or diabetes and offer self-management tools and peer support to improve overall health.
In addition, the CHW Outreach program offers bilingual/bicultural health literacy support, provides diabetic retinopathy tele-screening, teaches chronic disease self-management program classes in both English and Spanish, and teaches cooking-based nutrition classes to empower individuals to prepare healthy meals.
The CHWs are able to use the “Outreach Screening and Referral” (OSCAR) data system maintained and supported by CPC. OSCAR provides CHWs with a computer-based interface, a web server to synchronize tablets, and provides web applications for program administration. Linking OSCAR to EHRs at clinics could further favorably affect delivering cardiac health support to the community.