Cydnee Parsley is NACHC’s Deputy Director, Social Drivers of Health. Meg Meador is NACHC’s Director, Quality Improvement & Integration.
February is American Heart Month, a time dedicated to raising awareness about cardiovascular disease, the leading cause of death in the United States, affecting over 700,000 people annually. For communities that face barriers to getting the care they need and can afford, the stakes are even higher due to the disproportionate burden of heart disease and less access to care.
Community Health Centers (CHCs), with their mission to provide high-quality, comprehensive care to all people, are uniquely positioned to tackle this challenge by addressing not only clinical needs but also the social drivers of health (SDOH) that significantly impact cardiovascular outcomes.
The Link Between Social Drivers of Health and Heart Disease
Social drivers of health, such as food insecurity, housing instability, and transportation barriers, can lead to negative health behaviors such as lack of physical activity and lack of medication adherence which play a critical role in heart health. For example:
- Food Insecurity: Limited access to nutritious foods can lead to diets high in sodium, sugar, and unhealthy fats, increasing the risk of hypertension and heart disease.
- Housing Instability: Stress related to unsafe or unstable housing can exacerbate chronic conditions, limit opportunities for physical activity, which is important for maintaining heart health.
- Transportation Barriers: Without reliable transportation, patients may struggle to access preventive care or follow-up appointments, leading to poorly managed conditions like hypertension or diabetes.
By integrating SDOH screening tools such as PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences), CHCs are identifying these upstream factors and connecting patients to critical resources and services that support better heart health.
NACHC’s Million Hearts Initiative: A Blueprint for Success
By leveraging health IT systems to identify care opportunities, benchmark clinical outcomes, and integrate SDOH data, CHCs can design and implement interventions tailored to their unique communities, such as nutrition counseling, exercise programs, and smoking cessation services to address modifiable risk factors. The Million Hearts® initiative, co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS), aims to prevent 1 million heart attacks and strokes by focusing on translating evidence-based strategies into practice.
NACHC’s implementation of the Million Hearts® initiative was tailored to the unique needs of CHCs and their patients and designed to improve health outcomes, reduce health disparities, save lives, and lower health system costs.
Key components of NACHC’s Million Hearts® initiative included:
- Hypertension Management: CHCs identified undiagnosed hypertension and leveraged tools like self-measured blood pressure monitoring and team-based care approaches to improve hypertension outcomes. CHCs also used innovative clinical-community care models to engage patients.
- Cholesterol Management: CHCs enhanced workflows, used decision support tools, and educated care teams and patients to improve cholesterol screening and optimize use of statin therapy to prevent and treat cardiovascular disease.
Highlighting CHCs as 2024 Million Hearts® Hypertension Control Champion
Million Hearts Hypertension Control Champions are recognized for demonstrating their commitment to helping their patients with hypertension manage their blood pressure – achieving a hypertension control rate of at least 80%. Of the 32 Champions recognized in 2024, 15 were CHCs:
- Chota Community Health Services, Madisonville, Vonore, & Tellico Plains, TN
- Community Care of West Virginia, Rock Cave, West Virginia
- ConnextCare, Pulaski, New York
- Forest City Family Health Center, Forest City, Pennsylvania
- Hamlin Family Health Center, Lake Ariel, Pennsylvania
- Heart of Ohio Family Health Centers, Columbus, Ohio
- Mainline Health Systems, Inc., Dermott, Arkansas
- Marias Healthcare Services, Inc., Shelby, Montana
- NYC Health + Hospitals / Elmhurst, Elmhurst, New York
- Pike Family Health Center, Lords Valley, Pennsylvania
- Primary Care Partners Health Center, Warwick, Rhode Island
- Promise Community Health Center, Sioux Center, Iowa
- Valley Professionals Community Health Center, West Terre Haute, Indiana
- Warwick Health Center, Warwick, Rhode Island
- Wayne Memorial Community Health Centers, Honesdale, Pennsylvania
NACHC applauds these CHCs for their dedication to their patients’ heart health. Heart health is not just a clinical issue—it’s a community issue. Through the integration of SDOH, the adoption of innovative care models, and participation in initiatives like NACHC’s Million Hearts® program, health centers are paving the way for healthier hearts and healthier communities.
Learn more about NACHC’s Social Drivers of Health initiatives.
Learn more about the impact of NACHC’s Million Hearts Initiative.