Abstract TU113: Implementing a Community-based Cardiovascular-Kidney-Metabolic Health Program: An FQHC&AMC Partnership

Abstract

The community of Mattapan (Boston, MA, USA) holds one of the city’s highest rates of CVD-related mortality and shortened life expectancy with disproportionate incidence of cardiovascular kidney metabolic (CKM) conditions/sequelae (e.g. hypertension, myocardial infarction, stroke). To address this, a unique partnership between Mattapan Community Health Center, a federally qualified health center, and two AMCs, Boston Medical Center and MassGeneralBrigham, was created to promote CKM health. HEART of Communities is designed to: 1) provide a comprehensive multi-disciplinary care model (via NP, endocrinologist, nutritionist, pharmacist, CHW, and behavioral health care); 2) improve CKM health outcomes and patient engagement; 3) reduce racial health disparities related to adverse CKM events. Objectives: 1) Identify key implementation facilitators and barriers associated with CKM clinic care with a FQHC partnership 2) Understand target population and eligibility criteria relevant to CKM-related disparities 3) Understand risk stratification, program design, and balanced outcomes for evidence-based CKM care The HEART CKM team functions as a single patient-centered unit delivering care through group visits incorporating AHA-guideline directed pharmacotherapy, holistic lifestyle and mental health support, as well as resource allocation addressing unmet social needs like nutrition security and economic mobility. ~1620 patients are expected to enroll for a 6-month intervention over a 3-year period. Inclusion criteria for CKM (Stage 2) are having at least 2 of 3 conditions consistent with CKM (HTN, T2DM, overweight/obesity). All participants will be residents of Mattapan, ≥18 years, and have a primary or specialty care appointment w/in 18 months. Health assessments (AHA’s PREDICT 10-year CVD risk/Life’s Essential 8) and diagnostics will guide med titration. Patients will complete surveys before/after enrollment (PHQ-9, GAD-7, THRIVE). Preliminary data demonstrate feasibility and acceptability along with facilitators like team-based care and organizational alignment. Data capture for clinical outcomes and intervention fidelity are being tracked. This rare partnership centers equity, trust, and patient engagement by addressing CKM disease burden and reducing disparities. HEART seeks to impact the health, lives, and livelihood of the greater community and future partnerships may include expansion to additional communities facing similar disparities and severity of CVD disease.