Virginia Healthy Hearts Initiative

The Virginia Healthy Hearts Initiative is a public health initiative to prevent and manage hypertension among individuals and communities at high risk for cardiovascular disease. The Virginia Department of Health and its state and local partners implement community, clinical, and health system strategies within identified census tracts with the highest hypertension prevalence in the Commonwealth.

• Community: Healthy Hearts Learning Collaboratives are created locally to bring community members and partners together to identify barriers to heart health in the community and implement community-generated solutions. Residents of the identified census tracts make up 51% or higher of the members to preserve community members' decision-making power and ensure local Healthy Hearts Learning Collaborative best meets the needs and interests of their community. These Healthy Hearts Learning Collaboratives implement activities at the individual, community, systems, and policy levels.
• Clinical: Clinical activities include expanding team-based care in primary care settings through VDH's Chronic Care Management (CCM) model, Remote Patient Monitoring (RPM) and Transitions-of-Care (TOC) with pharmacists through the Community Pharmacy Enhanced Services Network (CPESN). Primary Care settings include Federally-Qualified Health Centers, independent medical practices, and senior medical centers.
• Health Systems and Community Partnerships: Health system and community partnership activities include partnering with hospitals and health systems to utilize their electronic health records and identify patients at high risk for cardiovascular disease, hiring Community Health Workers to conduct screenings for health-related social needs, and make referrals to health programs, social services, and other supports including healthy food, transportation, housing, employment, mental health services, and local resources.

The Centers for Disease Control and Prevention (CDC) awarded the Virginia Department of Health and its partners two federal grants in 2023: The National Cardiovascular Health Program and the Innovative Cardiovascular Health Program.

The National Cardiovascular Health Program is a 5-year program. It works to prevent and manage cardiovascular disease in those who are at risk. The program uses multiple strategies to address social and economic factors in communities and census tracts with high hypertension prevalence.

The Innovative Cardiovascular Health Program is a 5-year program. It focuses on identifying and responding to health care disparities in CVD within communities and census tracts with the highest hypertension prevalance. The goal is to improve related outcomes in those with hypertension and high cholesterol.  

Populations of focus for this award are adults aged 18 and older with a hypertension crude prevalence of 53% or higher, as shown by data specifically at the census tract level.

1. Track and Monitor Clinical and Social Services and Support Needs Measures Shown to Improve Health and Wellness, Health Care Quality, and Identify Patients at Highest Risk of Cardiovascular Disease (CVD) with a Focus on Hypertension and High Cholesterol. 
2. Implement Team-Based Care to Prevent and Reduce CVD Risk with a Focus on Hypertension and High Cholesterol Prevention, Detection, Control, and Management through the Mitigation of Social Support Barriers to Improve Outcomes. 
3. Link Community Resources and Clinical Services that Support Bidirectional Referrals, Self-Management, and Lifestyle Change to Address Social Determinants that Put the Priority Populations at Increased Risk for Cardiovascular Disease with a Focus on Hypertension and High Cholesterol. 

• Priority Population #1: Patients diagnosed with hypertension ages 45-85 years old 
• Priority Population #2: African American ages 18 years and older 
• Priority Population #3: African American pregnant and postpartum women 18 years and older. 
• Priority Population #4: Males ages 18 years and older 
• Priority Population #5: Individuals ages 18 years and older with a history of either hypertension, high blood cholesterol, cardiovascular disease, stroke, transient ischemic stroke, diabetes, tobacco use. 
• Priority Population #6: Adults screened for any of the following social determinants of health:  Low education, uninsured, unemployed, low income, inadequate access to care, or those experiencing adverse childhood events. 

How to find a SINGLE ADDRESS
that is within the program in the map above.

How to GEOCODE MULTIPLE ADDRESSES to identify their respective census tracts.