Tennessee Heart Health Network: Implementing Patient-Centered Practices in Primary Care to Improve Cardiovascular Health

Abstract Cardiovascular disease (CVD) is the primary cause of premature morbidity and mortality in the United States. Tennessee ranks 3rd in the U.S. in CVD event rates, 6th in CVD mortality, and 5th in stroke mortality. The state’s high prevalence of CVD is primarily linked to its disproportionate burden of CVD risk factors including

obesity, diabetes, and hypertension, and their associated modifiable health behaviors, including poor nutrition, sedentary lifestyle, and tobacco use. Patient-centered medical home initiatives hold some promise for reducing the burden of CVD in Tennessee. But these value-based purchasing endeavors have been insufficient by

themselves to support busy primary care practices in implementing patient-centered outcomes research (PCOR) approaches that reach beyond the traditional doctor-patient visit. An insufficient pipeline of primary care providers has made it even more critical to implement team-based care approaches that employ

telehealth and lay community health workers to engage patients in better self-care. Yet primary care providers and their team members have little time, knowledge, or resources to identify and implement these proven and financially sustainable PCOR evidence-based population health approaches. The goal of the Tennessee Heart

Health Network is to leverage existing infrastructure by identifying and implementing appropriate evidence- based interventions to improve quality and outcomes of CVD care across Tennessee. We will particularly target hypertension control and smoking cessation as two of the most potent CVD risk factors to reduce and/or

eliminate disparities in CVD outcomes and risks. We aim to: 1) Establish a statewide Cooperative external quality improvement (QI) support infrastructure, 2) Build a Network of primary care practices and related stakeholders who can utilize the Cooperative as a resource for QI support, 3) Develop a comprehensive,

multicomponent, evidence-based approach for a heart health improvement project to improve delivery of PCOR and build internal improvement capacity, 4) Conduct a robust evaluation of all phases of the project, 5) Disseminate interim findings, and 6) Integrate sustainability planning and develop a plan to maintain the

Cooperative and its Network of practices and professionals beyond the conclusion of the project. We expect to help primary care practices implement PCOR findings for Tennessee’s priority populations (e.g. African Americans with hypertension and people with obesity, diabetes, and CVD) to transform primary care and

measurably improve heart health care and outcomes.