ACHIEVE P3 - CHD

摘要 美国人的寿命和健康水平大幅提高，这要归功于 对风险因素的认识、检测和治疗并没有转化为黑人个人。预期寿命 黑人男性的比例仍然很低，与发展中国家不相上下。社会经济 身份、教育、邻里关系、建筑环境、社区环境和行为因素或社会因素 健康决定因素(SDoH)约占健康结果差异的80%，并在地理上形成聚集性。 解决黑人个人健康不平等问题的战略必须承认和解决SDoH。精密度 卫生技术、获得护理的协调以及关于生活方式、饮食和药物治疗的指导 传统上是特权的特权，但提供价值，凭借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，一个有远见的自由 精准医学方法，以识别“处于危险”的黑人。和使用务实的可报销的护理链接 中心促进、社区卫生工作者(CHW)主导、个性化、适应性强的生活方式和生活方式 环境(PAL2)干预，将改善最佳血压、血脂和血糖的三重目标 目标。PAL2将纳入经过验证的干预措施，包括CHW护理协调、激励性访谈、 生活方式指导，家庭血压监测，重要的是可以调整，以应对高风险 病人(CAC≥100)与护士-营养师-药剂师。我们将与凯霍加大都会 住房管理局(CMHA)，全国最大的补贴住房计划之一和更好的健康 伙伴关系(BHP)是一家总部位于克利夫兰的非营利性组织，提供CHW-Hub模式的医疗服务。利用一种实用的 强大的实施和可持续发展模式(PRISM)框架，用于解决RE-AIM领域(REACH x 功效：采用、实施、维护)和背景因素，我们的多学科团队将测试 可调PAL2干预的好处，以实现指导方针驱动的目标，同时探索上下文 可能决定我们干预成功的因素。

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.