{"id":519,"date":"2024-01-29T18:36:55","date_gmt":"2024-01-29T18:36:55","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/heart-disease\/?page_id=519"},"modified":"2026-03-11T18:33:06","modified_gmt":"2026-03-11T18:33:06","slug":"virginia-healthy-hearts-initiative","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/heart-disease\/virginia-healthy-hearts-initiative\/","title":{"rendered":"Virginia Healthy Hearts Initiative"},"content":{"rendered":"
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    1. <\/a><\/li>\n\t\t\t\t\t\t\t\t\t<\/ol>\n\n\t\t\t\t
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      Overview:<\/h3>\n
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      The Virginia Healthy Hearts Initiative<\/strong> 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.<\/p>\n<\/div>\n<\/div><\/div><\/div><\/div>

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      • Community<\/strong>: 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.<\/li>\n
      • Clinical<\/strong>: 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.<\/li>\n
      • Health Systems and Community Partnerships<\/strong>: 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.<\/li>\n<\/ul>\n<\/div>\n<\/div><\/div><\/div>
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        \n\t\t\t\t\t\t\t\t\t\t\t\t\t\tStatewide Partners (Current): \t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t
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        • Huddle Up Moms \u2013 Moms Under Pressure Program<\/span>\u00a0<\/span><\/li>\n
        • James Madison University - Institute for Innovation in Health and Human Resources<\/li>\n
        • Medical Society of Virginia Foundation<\/span> (Years 1-2)<\/span><\/li>\n
        • Unite Us<\/span>\u00a0<\/span><\/li>\n
        • United Way of Henry County and Martinsville<\/li>\n
        • Virginia Broadcast Solutions<\/span> (Year 1)<\/span><\/li>\n
        • Virginia Community Health Worker Association<\/span>\u00a0<\/span><\/li>\n
        • Virginia Department of Health \u2013 Stroke, Diabetes, Maternal Health, Tobacco Control, Oral Health, Arthritis, Brain Health Programs<\/span>\u00a0<\/span><\/li>\n<\/ul>\n
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          • Virginia Hospital and Healthcare Association<\/span> Foundation<\/span><\/li>\n
          • Virginia Pharmacy Association<\/span>\u00a0<\/span><\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/div>\n<\/div>\n<\/div><\/div><\/div>
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            \n\t\t\t\t\t\t\t\t\t\t\t\t\t\tCentral Region Partners (Current): \t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t
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            Halifax County:<\/p>\n

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            • Pittsylvania-Danville and Southside Health Districts<\/li>\n<\/ul>\n

              Petersburg:<\/span><\/p>\n

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              • Bon Secours Health System<\/span>\u00a0<\/span><\/li>\n
              • Bon Secours Southside Medical Center<\/span><\/li>\n
              • Calvary Temple<\/li>\n
              • Central Virginia Health Services - Petersburg Health Center<\/li>\n
              • City of Petersburg<\/li>\n
              • Claiborne Square Senior Apartments<\/li>\n
              • Crater Health District<\/span><\/li>\n
              • Encompass Health Rehabilitation Hospital of Petersburg<\/li>\n
              • Faith & Hope Temple COGIC<\/li>\n
              • First Baptist Church<\/li>\n
              • Gillfield Baptist Church<\/li>\n
              • Good Shepherd Baptist Church<\/li>\n
              • Harvest International Baptist Church<\/li>\n
              • Higher Way Ministries of Petersburg<\/li>\n
              • JenCare Senior Medical Center (Colonial Heights)<\/li>\n
              • Lafayette House<\/li>\n
              • Metropolitan Baptist Church<\/li>\n
              • Mount Olivet Baptist Church<\/li>\n
              • New Divine Worship Center<\/li>\n
              • Oak Street A.M.E. Zion Church<\/li>\n
              • Petersburg Department of Social Services<\/li>\n
              • Petersburg Healthy Hearts Learning Collaborative<\/li>\n
              • Petersburg Is Growing<\/li>\n
              • Royal Baptist Church<\/li>\n
              • Shalom Farms<\/li>\n
              • Trinity Baptist Church<\/li>\n
              • VCU Health<\/span>\u00a0<\/span><\/li>\n
              • Virginia Tech<\/li>\n
              • Walnut Hill Pharmacy<\/span>\u00a0<\/span><\/li>\n
              • Zion Baptist Church<\/li>\n<\/ul>\n

                Richmond and Henrico:<\/p>\n

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                • Bon Secours Health System<\/li>\n
                • Bon Secours St. Mary's Hospital<\/li>\n
                • JenCare Senior Medical Center (Hull Street)<\/li>\n
                • La Casa de la Salud<\/li>\n
                • Richmond and Henrico Health Districts<\/li>\n
                • VCU Health<\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/div>\n<\/div>\n<\/div><\/div><\/div>
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                  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\tEastern Region Partners (Current): \t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t
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                  Newport News \/ Hampton:<\/p>\n

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                  • Bon Secours Health System<\/li>\n
                  • Hampton and Peninsula Health Districts<\/li>\n
                  • Newport News Healthy Hearts Learning Collaborative<\/li>\n
                  • Riverside Regional Medical Center<\/li>\n<\/ul>\n

                    Norfolk:<\/p>\n

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                    • Eastern Virginia Medical School<\/span>\u00a0<\/span><\/li>\n
                    • Norfolk Health District\u00a0<\/span><\/li>\n
                    • Norfolk Healthy Hearts Learning Collaborative<\/li>\n
                    • Sentara Norfolk General Hospital<\/span>\u00a0<\/span><\/li>\n
                    • Sentara Leigh Hospital<\/span>\u00a0<\/span><\/li>\n<\/ul>\n

                      Portsmouth:<\/p>\n

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                      • Bon Secours Maryview Medical Center<\/li>\n
                      • City of Portsmouth<\/span><\/li>\n
                      • Healthy Portsmouth<\/span>\u00a0<\/span><\/li>\n
                      • Portsmouth Health District<\/li>\n
                      • Portsmouth Healthy Hearts Learning Collaborative<\/span><\/li>\n
                      • Silver Tree Seniors of Portsmouth<\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/div>\n<\/div>\n<\/div><\/div><\/div>
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                        \n\t\t\t\t\t\t\t\t\t\t\t\t\t\tSouthwest Region Partners (Current): \t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t
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                        Danville and Pittsylvania County:<\/p>\n

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                        • Pittsylvania-Danville and Southside Health Districts (Pittsylvania County and Danville)<\/li>\n
                        • Pittsylvania-Danville Healthy Hearts Learning Collaborative<\/li>\n
                        • Rural Health Association<\/li>\n
                        • The Health Collaborative<\/li>\n<\/ul>\n

                          Lynchburg:<\/p>\n

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                          • Centra Health<\/li>\n
                          • Central Virginia Health District<\/li>\n
                          • Johnson Health Center<\/li>\n
                          • Lynchburg Healthy Hearts Learning Collaborative<\/li>\n
                          • United Way of Central Virginia<\/li>\n<\/ul>\n

                            Martinsville and Henry County:<\/p>\n

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                            • Fieldale Community Center<\/li>\n
                            • Henry County Food Pantry<\/li>\n
                            • Martinsville Family Medicine<\/li>\n
                            • Martinsville-Henry County Healthy Hearts Learning Collaborative<\/li>\n
                            • United Way of Henry County and Martinsville<\/li>\n
                            • West Piedmont Health District<\/li>\n
                            • YMCA of Martinsville<\/li>\n<\/ul>\n

                              Roanoke:<\/p>\n

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                              • One Valley, Inc.<\/li>\n
                              • 727 Kombat Fitness Hub<\/li>\n
                              • Hunt Manor Apartments (part of the Roanoke Redevelopment and Housing Authority)<\/li>\n
                              • Roanoke City-Alleghany County Health Department<\/li>\n
                              • Fitness Fun with Tracy<\/li>\n
                              • Roanoke City Neighborhood Services<\/li>\n
                              • The Hill Church<\/li>\n
                              • Melrose Library<\/li>\n
                              • Hill Street Baptist Church<\/li>\n
                              • Gainsboro YMCA<\/li>\n
                              • Annwil Grocery<\/li>\n
                              • McCray Court Senior Living Center<\/li>\n
                              • Roanoke Redevelopment and Housing Authority<\/li>\n
                              • EnVision Center<\/li>\n
                              • Melrose Plaza<\/li>\n
                              • New Horizons Healthcare<\/li>\n
                              • LEAP (Local Environmental Agriculture Project)<\/li>\n
                              • Carilion Clinic<\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/div>\n<\/div>\n<\/div><\/div><\/div><\/div>

                                Background:<\/h3>\n
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                                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.<\/p>\n

                                The\u00a0<\/span>National Cardiovascular Health Program\u00a0<\/span><\/b>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.<\/span><\/p>\n

                                The Innovative Cardiovascular Health Program<\/strong><\/span><\/span> 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. <\/span>\u00a0<\/span><\/p>\n

                                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.<\/span><\/p>\n<\/div>\n<\/div><\/div><\/div><\/div>

                                Virginia Healthy Hearts Initiative Strategies:<\/h3>\n
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                                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.<\/span>\u00a0<\/span><\/li>\n
                                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.<\/span>\u00a0<\/span><\/li>\n
                                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.<\/span>\u00a0<\/span><\/li>\n<\/ol>\n<\/div>\n<\/div><\/div><\/div>

                                  Priority Populations:<\/h3>\n
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                                  • Priority Population #1<\/span><\/b>: Patients diagnosed with hypertension ages 45-85 years old<\/span>\u00a0<\/span><\/li>\n
                                  • Priority Population #2<\/span><\/b>: African American ages 18 years and older<\/span>\u00a0<\/span><\/li>\n
                                  • Priority Population #3<\/span><\/b>: African American pregnant and postpartum women 18 years and older.<\/span>\u00a0<\/span><\/li>\n
                                  • Priority Population #4<\/span><\/b>: Males ages 18 years and older<\/span>\u00a0<\/span><\/li>\n
                                  • Priority Population #5<\/span><\/b>: Individuals ages 18 years and older with a history of either hypertension, high blood cholesterol, cardiovascular disease, stroke, transient ischemic stroke, diabetes, tobacco use.<\/span>\u00a0<\/span><\/li>\n
                                  • Priority Population #6<\/span><\/b>: Adults screened for any of the following social determinants of health:\u00a0 Low education, uninsured, unemployed, low income, inadequate access to care, or those experiencing adverse childhood events.<\/span>\u00a0<\/span><\/li>\n<\/ul>\n<\/div>\n<\/div><\/div><\/div><\/div>

                                    VDH National and Innovative CVH Census Tracts Map<\/h3>\n
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