Heart of a Giant
Healthy Hearts
Communities
(2HC) Program
We are Striving to Build Happy, Safe Strong, Informed Healthy, Equitable Resilient, Inclusive Heart Healthy Communities.
The Boston Public Health Commission recently found that 25% of Boston adult residents–one in four– reported having high blood pressure (hypertension). The percentage of hypertension was higher for the following groups; Black (36%) and Latino (27%) adults, as compared with White adults (20%). The prevalence rates ranged from 34% to 42% in neighborhoods with predominantly Black people.
Multiple studies have proven that in addition to regular doctor visits, a home-based BP control program run by non-physicians can provide efficient, effective, and rapid control (suggesting an innovative paradigm) for hypertension management. In addition, such programs are effective, sustainable, adaptable, and scalable to fit current and emerging national healthcare systems.
In response, Heart of a Giant’s 2HC Program is set up to empower program participants to better manage and facilitate the prevention of high blood pressure through a culturally responsive, community-based, and technology-driven approach that provides comprehensive care tools, community-centered healthcare support, education, and guidance that engage and guide participants towards better health outcomes.
The mission of the HGF is to achieve better health outcomes for heart diseases and related chronic health conditions in our communities and enhance the quality of life through health education, care support, and connection to community resources.
The Healthy Hearts Communities Program (2HC) is an initiative to help individuals and families manage and prevent hypertension. We aim to achieve this through a culturally responsive, community-based, and technology-based approach, provides comprehensive healthcare support, health education, and coaching.
At HGF, we are driven by the African philosophy of Ubuntu, which emphasizes humanity, compassion, and social responsibility. We believe that instilling the philosophy of Ubuntu (“I am because we are”) as a core principle of our organization will significantly help improve our communities’ overall health and well-being.
Our Program incorporates successful and customizable Remote Patient Monitoring (RPM) to monitor Blood pressure and other vital signs through monitoring devices and services to monitor related cardio-metabolic conditions. In addition, we may provide blood glucose monitoring for participants at risk of or living with Diabetes.
We collaborate with local healthcare providers and centers to recruit and support their patients and caregivers. In addition, we provide healthcare providers services to help the following outcomes for the participants.
See below for more information about the delivery methods and expected outcomes for each of the four pillars of the 2HC Program.
Heart of a Giant
Our Community Care Team, composed of health professionals, provides personalized clinical care support to address participants’ health needs and, when applicable, augment their prescribed care plans at home or a familiar place. They will teach participants how to self-monitor BP at home and make available monitoring systems. Participants will receive sets of home blood monitoring devices to develop the habit of monitoring their blood pressure and other vital signs at home. The biometric data will automatically be communicated to the Program Team. If no remote communications links are available, Care Coordinators will contact the participants to collect the data in person or via phone.
The Community Care Team also leverages audiovisual resources and digital health technology to facilitate, promote, and enhance health education and remote care support. In addition to their personalized level of care, participants can access online tools to help educate, coach, and help them track their progress, highlight red flags, and encourage best practices. The team will regularly visit in-person or virtually and contact using other multiple channels to communicate with the participants, including phone or Web messaging. All related communications will be HIPAA-compliant.
Methods of Delivery:
Care Support at Home entails the following:
- Care coordination and referral to hypertension treatment programs or cardiology centers (when applicable)
- Heart health education and vital signs monitoring: blood pressure, BMI, glucose, total lipogram, cholesterol, lifestyle diet and nutrition, activity level…
- Risk-factor evaluation and education
- Personal nutrition evaluation and weight management
- Medication adherence per the physician’s prescription (when applicable)
Expected outcomes
- Care optimization
- Develop patient advocacy
- Improved patient compliance
- Improved medication adherence
- Improved patient-physician relationships
Our Community Care Team help participants develop their individualized SMART goals and achieve them through evidence-based interventions.
Physical Activity
Physical activity can help control blood pressure and weight, strengthen the heart, and lower stress levels. Moderate-intensity aerobic exercise has been proven to prevent hypertension and help manage stage 1 hypertension. Dynamic resistance exercises, if done correctly, also contribute to lowering both systolic and diastolic blood pressures. The aim is to help participants whose medical providers have cleared them to begin participating in physical activity regularly, increase their physical endurance and muscular strength, and improve their mood by reducing the risk of hypertension and other heart diseases.
Healthy Diet and Nutrition
A healthy diet and nutrition play a significant role in sustaining a healthy weight, healthy emotional state, and well-managed blood pressure. The goal is to help our participants with the tools to help them eat better. Our Community Care Team supports participants in following a heart-healthy diet and eating plan. In addition, participants will receive complimentary grocery vouchers to promote healthy shopping and be presented with nutritional lessons and cooking classes.
Sleep Hygiene
Sleep disturbances are among heart disease patients’ most commonly reported symptoms. Our Care Team supports the participants in improving their quality and quantity of sleep. They provide recommendations for assessing sleep disturbances and recommend they visit a sleep medicine specialist.
Quitting Smoking
For the participants seeking to quit smoking, the Care Team helps them connect with expert quitting information from public health authorities and have them talk to a smoking counselor individually or in a group. They can also get free, confidential coaching through a telephone quitline. Lastly, the team will guide them to their medical team if needed.
Alcohol Abuse
Community Care Coordinators will also support those struggling with alcohol abuse. We will recommend that they contact their primary provider or refer them to a local alcohol addiction treatment program.
Methods of Delivery
The Lifestyle and Behavioural Change Support will entail two to three 30-to-60 mins weekly exercise sessions. They will begin in the 2nd month of the program. Activities include exercising, nutrition counseling, and education.
Each member will receive:
- An initial assessment and a fitness level measurement
- A semi-supervised exercise training program
- Farmers markets, community and group events in person or online
- Dietary and weight management classes
- For non-gym members, a 3-to-6-month membership at a local gym
- Weekly medically-tailored meals delivered by our partners such as Community Servings (If Applicable)
Expected outcomes
- Increased physical endurance and muscular strength
- (Healthier weight and better weight management )Achieve and maintain a healthy weight
- Improved emotional well-being and better metabolism
Health Literacy and Emotional well-being are critical to maintaining healthy blood pressure. We facilitate health and well-being through access to mental health and other counseling, social workers, activities groups, and partner services. In addition, the program utilizes available screening tools to assess the participants’ mental health and well-being to identify opportunities to support them and their relatives.
Our Education and Coaching offer thematic health lessons. In addition to the core topics of high blood pressure, heart disease, and diabetes, this component will cover self-care management, self-advocacy, nutrition, and appropriate physical activity. The sessions are designed to meet the needs of community members regardless of educational achievement and health literacy levels. The classes will include: controlling blood pressure, eating heart-healthy, heart attack, stroke, and risk factors, knowing diabetes, learning hands-only CPR, heart health advocacy, and more.
Multiple communication channels will be used, including phone calls, chats, educational videos, lessons, printed guidance materials, activity notebooks, pedometers or apps, cookbooks, and additional resources, all in compliance with HIPAA regulations.
Methods of Delivery
Our Community Care Team works with medical providers and other health professionals, such as dieticians and researchers, to support participants. In addition, our partner Social Clinical Worker provides complimentary psychotherapy sessions to the participants, including screening sessions and, where applicable, escalations and referrals.
The Community Care Team will provide the following services to our participants:
- Developing individualized action plans.
- Biometric self-measurements
- Documentation and use of devices
- Encourage the use of a personal health diary
- Heart health advocacy
Expected outcomes
- Better knowledge of hypertension
- Self-report of improved behaviors
- Improved systolic blood pressure, weight, fasting glucose
- Recommend a therapy plan or, if needed, make referrals to a specialist(s)
HGF believes that social support and network characteristics are important in the onset and management of hypertension. As such, behavioral change interventions should consider participants’ social networks.
Awareness of patients’ social support and social network can help to develop effective and tailored interventions based on the network characteristics for improving treatment outcomes and lifestyle behaviors. For example, regarding behavioral adherence, they found that patients with more practical support from friends were likelier to adhere to behavioral recommendations.
A key component of social enhancements is linking program participants to peers, program alums, and local health and public health professionals. A community to promote and facilitate peer support and engage in hobbies, community, and cultural activities to promote their overall well-being and health outcomes goals.
Methods of Delivery
- Regular in-person and remote support group activities
- Access to a virtual community
- A mix of activities, such as Information sessions with health and wellness professionals or peer networking sessions
- Participation in community and social activities
Expected outcomes
- Meet and learn from other people with high blood pressure and heart diseases.
- Nurture a sense of belonging in an engaged community
- Improve patient-physician relationships
- Create a support network
- Promote an active and a healthy lifestyle
- Improve the physical and emotional well-being of those at risk and affected by hypertension.
Our programs are open and free to hypertension patients, at-risk people, relatives, and caregivers in Boston, MA.
857 425-6320
info@heartofagiant.org,
This program is made possible by our generous partners and supporters.
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