ASTHO Heart Disease and Stroke Prevention Learning Collaborative: Insights from National Partners

June 20, 2017|4:38 a.m.| ASTHO Staff

ASTHO’s Heart Disease and Stroke Prevention State Learning Collaborative has transformed the way state public health leaders and their partners are working to prevent, detect, and treat hypertension and chronic diseases. The collaborative has helped states reach more people living with diagnosed and undiagnosed hypertension and builds on lessons learned from nationwide efforts to reduce the risk factors associated with heart disease and stroke.

The collaborative also challenges public health professionals to think beyond traditional partnerships to work with champions in both healthcare and community settings. To drive this important aspect of the work, ASTHO engages a network of partner organizations who provide leadership, expertise, and recommendations for elevating heart disease and stroke prevention initiatives among their respective members and constituents. Organizations involved in this network include the Association of Public Health Nurses (APHN), the National Association of County and City Health Officials (NACCHO), the National Association of Chronic Disease Directors (NACDD), and the National Forum for Heart Disease and Stroke Prevention (National Forum).

Since hypertension is a multifaceted public health problem, each organization calibrates its approach to target different challenges that state and local public health agencies may face related to blood pressure control, health IT, and team-based care. Examples of these initiatives include developing public awareness campaigns, community health improvement plans, hypertension screening protocols, and data tools to identify health disparities. ASTHO and its national partners are working toward a common goal by ensuring the coordination of public health, clinical care, and policy approaches.

  • The National Forum, for example, created the Counter Cholesterol campaign to respond to the growing number of Americans who have or are at risk for high cholesterol.
  • NACDD’s cardiovascular health initiative has been successful in working with state chronic disease programs to identify health disparities in hypertension control and scale up blood pressure control activities in clinical practices.
  • For APHN, public health nurses play an integral role in working with communities to design protocols for hypertension, along with strategies to refer patients to healthcare providers.
  • NACCHO is helping local health departments see the value of leveraging community health assessments to generate linkages between community and clinical partners toward improved rates of hypertension.

In May, ASTHO reached out to its national partners to learn how each organization addresses decisionmaking, policy opportunities, skill-building for today’s public health workforce.

In terms of outlining priorities for your organization’s hypertension prevention and control efforts, what has influenced or guided your decisionmaking process?

National Forum Executive Director John Clymer: First, we ask, what can National Forum members do to increase the numbers of people with high blood pressure who have it under control? Being an organization of organizations, with over 85 members in the public, private, and nonprofit sectors, we're here to be a catalyst, for not only collaboration among our members and across those sectors, but also to empower and enable our members to carry out their missions, their purpose, more effectively. The National Forum's strategic priorities are simple. They're the “ABCs” of cardiovascular disease prevention, so increasing use of aspirin and appropriate anticoagulants, controlling blood pressure, managing cholesterol, and reducing smoking. Then, our overarching goal is to eliminate cardiovascular health disparities and achieve health equity. How do we do that? I think communication with our members and stakeholders is essential, so we inform, we share, and most importantly, we listen to them.

NACCHO Interim Executive Director William Barnes: At NACCHO, we address high blood pressure at the community level to understand the “how,” “why,” “what,” “when,” and “where” so that evidence-based interventions can be tailored to individual communities and the high-risk populations within them. But, many local health departments (LHDs) need help with workforce capabilities to carry out these interventions. As we make the transition to more community-driven public health approaches, many LHDs have been successful in identifying local health problems and combatting these issues with a range of evidence-based strategies. However, some departments are not yet comfortable facilitating linkages between local healthcare providers, community partners, stakeholders, and the community at large.

NACCHO Chief of Government Affairs Laura Hanen: Local health departments need support to embody the community health strategist role to form those linkages with broad swaths of the community. NACCHO supports LHDs in becoming facilitators and creating these crucial linkages between physicians and community programs to serve high-risk populations. Part of this role involves conducting community health assessments and community health improvement plans. We have tools that focus on community engagement and collaborative participation, including NACCHO’s Mobilizing for Action Through Planning and Partnerships (MAPP).

APHN Executive Director Shirley Orr: APHN is focused on developing and supporting the role of community/public health (C/PH) nurses. We work to align the C/PH nurses with state health agencies and officials for collective impact. Our partnership with ASTHO and the Million Hearts State Learning Collaborative has allowed us to organize efforts around hypertension prevention and help our members understand the importance of it.

NACDD Director of Programs Marti Macchi: NACDD is an organization that represents all states and jurisdictions, so we always look through the lens of what the states are being asked to implement, how our work can align with what they're doing, and what the CDC's priorities are. In terms of hypertension identification and control, we focus on undiagnosed hypertension, quality of care for people with hypertension, and encouraging team-based approaches to management. We believe in supporting capacity-building and providing technical assistance to state health departments, which we carry out by offering learning opportunities, creating newsletters and other tools, and connecting them to their peers in other states. NACDD is committed to sustained funding to state health departments and supporting their work, and so it’s important that we educate policymakers on evidence-based approaches for hypertension and other chronic diseases, help them understand the value of those programs, and make sure that funding remains in place for states to continue this work.

Considering today’s public health landscape, what are some of the biggest policy opportunities for health officials to address hypertension?

Clymer: I think all of us in public health recognize that we're here to address two things. One is urgent threats to the public's health, and the second is the urgent realities, like the rising tide of chronic disease in the U.S. There is consensus across the political spectrum that being able to prepare for and respond to urgent threats is a priority. Where we're on much less firm ground is in our ability to address the urgent realities that are threatening, and in some cases undermining, the vitality of families, and of communities, and even military preparedness, where we see a rising tide of risk factors that lead to chronic disease, such as obesity and other unhealthy behaviors. Those have real costs in both human and economic terms. These risk factors are often underrecognized by policymakers, so it's imperative that we who are most familiar with them, and who have 20/20 vision of them, step up and help policymakers how to make it easier for people to make healthy choices in their everyday lives, and to equip and invest in public health and population health strategies and programs and policies that will reduce the burden of those urgent realities.

Hanen: At a policy level, decreasing the risk for chronic disease and hypertension has become a priority for healthcare providers, payers, governments, and insurers and we have seen a shift towards value-based care, along with greater reporting and implementation of quality improvement initiatives. Health departments are on the front lines, adopting policies rooted in evidence-based interventions and providing guidance on these interventions targeted towards eliminating health disparities. Health officials can initiate change through the lens of Health in All Policies, which inherently recognizes that the social determinants of health have a far greater impact on health than genetics or behavior change alone.

Orr: Funding and reimbursement for prevention programs is not just for healthcare providers. We must support interprofessional efforts in communities that reach beyond healthcare institutions and across sectors. If we want to truly address the social determinants of health, then we need to address policies related to food production, safe housing, and environmental concerns.

Macchi: In terms of evidence-based approaches, there are many opportunities to better support team-based care and other strategies, such as self-measured blood pressure. The right team, including the patient, primary care provider, and others, such as pharmacists, nurses, and community health workers can help to improve quality of care. Another example is self-measured blood pressure monitoring that's tied to clinical support. The evidence shows it is an effective way to improve hypertension control, but reimbursement for those monitors is very low, or non-existent. To the extent that they can, today's health officers and chronic disease and health promotion directors should work with providers and payers in their state, or at least discuss the impact of providing self-measured blood pressure monitoring devices and making sure there's clinical support to go along with it. By supporting a more comprehensive approach to patient care, which includes a number of different specialties, and by empowering the patient, we can help to address chronic diseases in this new public health landscape.

In your opinion, what are the most important skills, tools, or resources that public health leaders need to have in order to successfully address hypertension in their jurisdictions?

Clymer: Focus, persistence, and empathic communication. First is strategic focus. Janet Wright, the executive director of Million Hearts, has said that success comes when one focuses on a small set of high-impact measures. Second is persistence. Just because we know something works doesn't mean everybody knows it, and just because we know something is a priority and deserves focus doesn't mean everybody has that knowledge, and so it's incumbent on us to be persistent in our efforts and in our message. Third is empathic communication. We need to be able to talk with stakeholders in terms of what matters to them, in terms of what's important to them, and what resonates with them and their values.

Barnes: The fundamental purpose of public health is defined by three core functions: assessment, policy development, and assurance. To rise to the challenge of a public health crisis like hypertension, training must pivot around these functions, including a familiarity with community linkages and how to implement tools, such as community health assessments and community health improvement plans, to carry out evidence-based interventions that effect change. Training must also address forming cross-sector linkages, with an emphasis on increased collaboration between stakeholders and various partners in both the urban and rural settings. Leaders also need to be trained to identify high-risk populations within their communities and develop interventions that benefit them. This will help promote health equity and eliminate health disparities, which often exist along racial, economic, educational, and geographic lines. Providing tools and resources to understand the root causes of these disparities and addressing them by implementing well-suited, evidence-based interventions is important to combat high blood pressure.

Orr: The C/PH nursing workforce is challenged with constraints, such as funding, that limit the fulfillment of roles beyond only the clinical. C/PHNs are more than providers of care—they are system catalysts. While they have the clinical skills to monitor blood pressure and medication adherence, they also have skills to care for the health of populations. With these skills, C/PH nurses can help health officials lead systems change, direct their focus more on population health, and bridge public health and health systems.

Macchi: We're seeing a lot of skill gaps, things that we, as an association, are trying to address, and many of them relate to the changing face of public health. In general, I would categorize them as payment reform, health informatics that could enhance quality improvement, and the ability to have GIS information that can help us to identify not only the gaps, but also the successes. The work has changed over the last several years, in terms of the priorities on which state health departments are being asked to focus, such as reimbursement, redesign, or payment reform, and working with payers and health plans. Those conversations are difficult just in terms of the different “languages” spoken by each sector. The other issue is using data to drive decisionmaking. We talk a lot about quality improvement and we're doing better there—as far as where public health intersects with health system interventions—but that is certainly an area where we could see more skill development. Third, is the ability to use GIS to map where our underlying socioeconomic issues exist. It not only can only highlight where the need is, but it also can highlight where things are actually working!

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Learn more about ASTHO’s Heart Disease and Stroke Prevention Learning Collaborative:

www.astho.org/Million-Hearts/State-Learning-Collaborative-to-Improve-Blood-Pressure-Control