The purpose of this Request for Grant Applications (RFGA) is focused on addressing health disparities and social determinants of health related to CVD within specific targeted census tracts. The initiative aims to introduce innovative clinical and pharmaceutical services in areas where infrastructure and services are currently lacking. 9.2 Mitigating Social Vulnerabilities 9.2.1. The Subrecipient shall offer services designed to alleviate social vulnerabilities present in the targeted census tracts. These vulnerabilities include: 9.2.1.1. High poverty rates. 9.2.1.2. Significant disability rates. 9.2.1.3. High numbers of residents residing in mobile homes. 9.2.1.4. Veteran populations. 9.2.1.5. Seniors. 9.3 Medical Therapy Management and Blood Pressure Monitoring 9.3.1. As part of the grant's scope, Medical Therapy Management (MTM) and Self-Measured Blood Pressure Monitoring (SMBP) shall be included. These services aim to improve blood pressure control and reduce related health disparities among adults in the targeted census tracts. 9.4 Enhancing Communication and Coordination 9.4.1. The Subrecipient shall facilitate increased communication and coordination among care team members, including both clinical and social service providers. This effort includes the innovation of electronic health records and referral systems to support bi-directional referrals and tracking of: 9.4.1.1. Clinical measures. 9.4.1.2. Quality measures. 9.4.1.3. Social service and support needs.
