ACHIEVE P3 - CHD

摘要 美国人寿命和健康寿命的大幅提高，归因于 对危险因素的认识、检测和治疗尚未转化为黑人个体。预期寿命 在黑人男性中，这一比例仍然很低，与发展中国家相当。社会经济 地位，教育，邻里，建筑环境，社区背景和行为因素或社会 健康决定因素（SDoH）占健康结果方差的约80%，并在地理上聚集。 解决黑人健康不平等问题的战略必须承认和解决SDoH问题。精度 保健技术、获得保健协调和生活方式指导、饮食和药物治疗， 传统上是特权者的特权，但由于其准确性和共同利益， 参与、教育和赋权。项目3的总体假设是， 精准医学方法来识别“高危”黑人。和联系，以照顾使用一个务实的偿还 HUB促进，社区卫生工作者（CHW）领导，个性化，适应性强的生活方式和生活方式 环境（PAL 2）干预，将改善最佳血压，血脂和血糖的三重目标 目标的PAL 2将纳入经过验证的干预措施，包括CHW护理协调，动机访谈， 生活方式指导，家庭血压监测，重要的是将可调，以解决高风险 患者（CAC≥100）与护士-营养师-药剂师。我们将与凯霍加大都会合作， 住房管理局（CMHA），全国最大的补贴住房计划之一，更好的健康 伙伴关系（BHP），一个克利夫兰的非营利组织，提供CHW-HUB模式的护理。利用实用 稳健的实施和可持续性模型（PRISM）框架，以解决RE-AIM领域的问题（Reach x 有效性：采用、实施、维护）和环境因素，我们的多学科团队将测试 可调PAL 2干预的好处是，在探索环境因素的同时， 这些因素可能决定我们的干预是否成功。

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.