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

摘要 心血管疾病（CVD）是美国过早发病和死亡的主要原因。 田纳西州在美国CVD事件发生率中排名第3，CVD死亡率排名第6，中风死亡率排名第5。的 该州CVD的高患病率主要与CVD风险因素的不成比例的负担有关，包括 肥胖、糖尿病和高血压，以及与之相关的可改变的健康行为，包括营养不良， 久坐不动的生活方式和烟草使用。以患者为中心的医疗之家计划有望减少 田纳西州心血管疾病的负担。但是，这些基于价值的采购努力已经不够， 支持忙碌的初级保健实践，实施以病人为中心的成果研究 变革和组织振兴方案（变革和组织振兴方案）的做法超越了传统的医生-患者访问。一级供应不足 护理提供者使实施基于团队的护理方法变得更加重要， 远程保健和非专业社区保健工作者使病人更好地自我保健。然而，初级保健提供者 他们的团队成员几乎没有时间、知识或资源来识别和实施这些经过验证的， 财政上可持续的变革和组织振兴方案循证人口健康办法。田纳西之心的目标 健康网络将通过确定和实施适当的证据来利用现有的基础设施- 基于干预措施，以提高田纳西州CVD护理的质量和结果。我们将特别 将高血压控制和戒烟作为两个最有效的CVD风险因素，以减少和/或 消除CVD结果和风险的差异。我们的目标是：1）建立一个全国性的合作外部 质量改进（QI）支持基础设施，2）建立初级保健实践和相关网络 可以利用合作社作为QI支持资源的利益相关者，3）制定全面的， 心脏健康改善项目的多成分循证方法，以改善 变革和组织振兴方案并建立内部改进能力，4）对项目的所有阶段进行强有力的评价，5） 传播中期调查结果，以及6）整合可持续性规划，并制定一项计划， 合作社及其实践和专业人士的网络超出了项目的结论。我们期望 帮助初级保健实践部门针对田纳西州的重点人群（如非洲人）实施变革和组织振兴方案的调查结果 美国高血压患者和肥胖、糖尿病和心血管疾病患者），以改变初级保健和 显著改善心脏健康护理和结果。

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.