Mississippi Alliance for Cardiovascular Health Request for Application (RFA): Enhancing Community and Clinical Partnerships for Improved Blood Pressure Control (Health Systems)

Through this RFA, the Heart Disease and Stroke Prevention Program will award up to 10 healthcare systems a contract for participating in the Mississippi Alliance for Cardiovascular Health (MACH) Learning Collaborative (LC). The MACH LC is designed to improve hypertension and cholesterol management in underserved communities by addressing social determinants of health, with goals centered on enhancing healthcare quality and accessibility. It builds on prior initiatives, such as the Chronic Disease Quality Improvement Initiative (CDQII), which has previously shown success in improving chronic disease management. This collaborative effort emphasizes the role of healthcare systems in working with community organizations to improve CVD outcomes and reduce disparities across Mississippi. Applications are evaluated based on organizational capacity, which includes the ability to secure a dedicated Community Health Worker, project management, data reporting capabilities, collaboration efforts, and resource availability. Successful applicants will form multidisciplinary teams, engage in regular learning sessions and operational site visits, and report monthly/quarterly on clinical and social data. The LC will utilize three main strategies: 1. Identifying, Managing, and Treating : Focus on identifying patients at high-risk for CVD and addressing both clinical and social support needs. 2. Team-Based Care : Implement collaborative, multidisciplinary care teams to manage CVD and associated risk factors. 3. Community-Clinical Linkages : Facilitate closed-loop referrals and self-management support by connecting patients to clinical services and community resources. Up to 10 eligible healthcare systems will receive $30,000 annually over the next three years, based on performance. Eligible applicants include primary care practices, rural clinics, and Federally Qualified Health Centers (FQHCs) serving adults, 18 years or older. Priority counties are Amite, Calhoun, Claiborne, Clarke, Covington, Franklin, George, Greene, Grenada, Harrison, Jefferson, Jefferson-Davis, Lauderdale, Lawrence, Leake, Montgomery, Neshoba, Noxubee, Prentiss, Pike, Scott, Tippah, Tishomingo, Webster, Wilkinson, Yalobusha.