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 mood by reducing the risk of hypertension and other heart diseases.

Healthy Diet and Nutrition

A healthy diet and nutrition play a large 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 to follow a heart-healthy diet and eating plan. 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 wellbeing 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)