In 2010, the healthcare spending and lost productivity (direct and indirect costs) due to cardiovascular disease (CVD) exceeded $400 billion, making it the most costly disease in the United States. Although the past few decades have seen steady decreases in cardiovascular disease risk overall, there are important racial, geographic and socioeconomic health disparities that persist among certain subgroups of people. These health disparities are preventable differences in the indicators of health of different population groups. Given New York City’s large uninsured, under-insured, and underserved population—one of the largest among urban areas in the United States—innovative methods are necessary to tackle the growing burden of CVD.
Although CVD and diabetes are often manageable, more cost-effective treatment options are available in the form of prevention and early intervention. To address and reduce the severity of CVD and diabetes in these populations, innovative health interventions with active community participation are necessary. The Diabetes Prevention Program Research Group found lifestyle changes to be the most effective intervention preventing diabetes in at-risk populations when compared to Metformin and placebo, leading to the prevention of an additional 3.2 cases of diabetes per 100 person-years(1). Similarly, the American Heart Association cites various studies which have tested a variety of exercise programs and found that these interventions were effective at reducing systolic and diastolic blood pressure, increasing HDL, decreasing LDL and triglycerides, and reducing insulin resistance and glucose intolerance(2). All these factors likely reduce the risk of a cardiovascular event. Consequently, relatively simple interventions, performed consistently and with appropriate follow up, stand to prevent significant amounts of disease and disability in underserved populations.
The Heart-to-Heart Community Outreach Program was conceived of by Jonathan D. Moreno and Suchit H. Patel, two MD/PhD students at Weill Cornell Medical College. While leading the Weill Cornell Community Clinic, a student-run free clinic for the uninsured, they realized that the majority of patients seen at the clinic carried a primary diagnosis of CVD. The program was developed with the idea of mobilizing a primary care infrastructure and “bringing the clinic to the community” to actively find new cases of undiagnosed and undertreated CVD, and then transition those participants to more permanent health care solutions. By using innovative tools and strategies to reach those most in need, the program empowers participants to make beneficial lifestyle changes based on personal CVD risk.
The target community was initially defined as New York City residents who were underserved by the local healthcare infrastructure. Prior to the start of the program, the team reached out to the CTSC and was connected to the community representative of the CTSC External Advisory Board, Reverend Patrick O’Connor. Reverend O’Connor, who is himself African-American, leads a historic Presbyterian church located near several predominantly low-income African American and Hispanic neighborhoods in New York City. The founding students learned of a prostate health screening event that took place annually at the church in partnership with the Department of Urology at Weill Cornell Medicine. The pastor invited the program to hold its first event concurrently with the annual prostate screening.
At the first event, the founding medical students were introduced to the chief of staff of a local New York State Senator, who invited them to schedule several events in partnership with the state senator’s office. While these events were organized, CTSC program staff simultaneously created a CTSC Community Advisory Board and established connections with numerous faith-based community organizations throughout NYC to identify additional program sites with significant representation among people from underserved communities. However, word of mouth turned out to be the greatest source of creating new community partnerships. Several individuals who attended the first events invited organizers to host events at their churches. Clergy and church leaders shared information about the program with their contacts at professional meetings, resulting in additional invitations. By the third year, such requests were so abundant that new sites could be identified with little proactive effort on the part of program organizers.
Two significant changes were made to the program immediately after the first event. First, there was recognition that there was insufficient Spanish-speaking representation among staff and volunteers. Recognizing this shortcoming, organizers recruited Spanish speaking volunteers to improve engagement of participants in subsequent years. The second significant change was the addition of student volunteers to escort participants through the screening process and to assist in the administration of study surveys. Initially, participants were asked to complete the surveys and move from station to station by themselves, often resulting in confusion and incomplete/incorrectly filled out surveys.
Despite these initial issues, the program almost immediately received a positive response from the community. It became apparent to community leaders and program organizers that H2H was providing a valuable and innovative model for healthcare screening and health education.
For the first few years, the role of the CTSC was to provide funding, as well as administrative and logistical support. Recognizing the success and growth of the program, the CTSC became more deeply involved in the program over the years, eventually handling most of the program planning, logistics and coordination, while also helping to lay out the program’s scientific goals in detail.
Five years into the program, two MD/PhD students interested in ophthalmology developed a 3D-printed iPhone adapter that would allow for retinal imaging without dedicated medical equipment. Seeking a forum to assess the utility, performance, and user acceptance of their new device, they successfully submitted a CTSC pilot grant application proposing to supplement the H2H program with ophthalmology screenings. The IRB protocol was modified to include provisions that would allow the students to employ the imaging device and collect data at H2H events. While the retinal imaging device study has concluded, the ophthalmology screenings, supported by a dedicated group of students and physicians, continues to be offered.
In 2016, the H2H Medical Director learned that leadership of NewYork-Presbyterian Hospital’s Dietetic Internship program was seeking an opportunity to provide their interns with community health experience. As an outcome of discussions that followed, the H2H program was expanded to include nutrition counseling. At many events, participants receive culturally and medically tailored nutrition handouts, including modified recipes, as well as nutrition consultations from dietetic interns overseen by their Registered Dietician instructors.
The H2H program was especially embraced by community leaders because it was the first comprehensive program most had encountered. While there were some other programs that offered singular point of care testing (lipid, blood pressure, mammograms, etc.), none were integrated into a comprehensive program that provided multiple tests, included referrals to follow-up care and insurance enrollment, and most importantly, offered medical consultations on site. This trust was further cemented by the fact that the program would return yearly.
The H2H Campaign is administered by a core team through the WCM CTSC’s Community Engagement and Research Component. Jeff Zhu, the Managing Director of the component, has been involved since program inception and has served as a consistent community point of contact and institutional knowledge over the years. A specific aim of the program is to introduce students to the concept of multidisciplinary team-based health care. Volunteers are recruited from WCM, NewYork Presbyterian Hospital, and Hunter College (HC). WCM volunteers include medical, physician assistant, and registered dietician students. HC volunteers include undergraduates from the college interested in exploring the health professions, as well as from professional programs, specifically nursing. The core team is responsible for oversight of the program, management of student volunteers, and coordination of events. In addition to the student volunteers, the program recruits licensed medical professionals (physicians, nurse practitioners, or physician assistants) from WCMC and HC to carry out standardized educational counseling based on the current Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8)(3), Guideline on the Management of Blood Cholesterol(4), and American Diabetes Association (ADA) guidelines(5). The program requires that there be at least one attending physician at each event to provide medical supervision.
Comprehensive screenings are held in spaces provided by community centers and faith-based organizations where participant familiarity and trust is already firmly established, thereby decreasing the barriers (real and perceived) to engaging with the traditional medical establishment. Each participant is assessed for the traditional anthropomorphic measures (height, weight, body-mass-index (BMI), blood pressure, and waist circumference), as well as biochemical measures (blood glucose, hemoglobin A1C and a complete lipid panel – HDL, LDL, total cholesterol, and triglycerides). After the screening is performed, participants meet with a physician who explains their results and provides individualized follow-up information.
Through socioeconomic and demographic history, this program also seeks to understand the factors that contribute to an increased disease burden in these at-risk populations. By engaging communities at the local level, the Heart-to-Heart campaign has the potential to further our current understanding of how behavior, lifestyle choices, and knowledge of CVD impact differences in risk and future health care decision-making.
Weill Cornell Clinical and Translational Science Center
Weill Cornell Medicine, Department of Ophthalmology
Weill Cornell Medicine, Department of Primary Care
Weill Cornell Community Clinic
Hunter College School of Nursing