We must use all data assets to better characterize individuals, populations, and communities; promote engagement and partnership; and better tailor primordial and primary prevention strategies to meet the needs of large and diverse populations.
Research
Current Projects
PCHY supports research in basic and translational science, clinical trials, digital health and real world data studies, along with epidemiology and population health. We work with trainees at all levels to develop skills and forge new scientific discovery related to genetics, imaging, risk-reductive medications and lifestyle interventions, remote patient monitoring, digital therapeutics, clinical and patient-reported outcomes and health disparities.
Hypertension
PCHY offers a state-of-the-art program to manage hypertension. The program combines the expertise of cardiologists, pharmacists and community health workers and leverages digital health and telemedicine. The program is designed to provide a personalized, low-burden, high-touch approach to blood pressure control.
Consistent with current guidelines for blood pressure control, patients are instructed on how to monitor their blood pressure at home. We equip patients with a home blood pressure cuff that syncs with their phone. The data streams through MyChart and is monitored by pharmacists. Our pharmacists conduct weekly or bi-weekly telehealth visits with patients addressing factors contributing blood pressure control, including side effects and medication cost. The goal is to control blood pressure within 6 to 12 weeks.
Our team is also working to better understand phenotypes of hypertension, combining data from ambulatory blood pressure monitors, sleep and activity monitors, ecological momentary assessment, and social and contextual factors. This work is being done as part of a National Institute on Minority Health and Health Disparities Center grant called, the Eastern Caribbean Health Outcomes Research Network (ECHORN). This is a prospective, multi-center study among adults in Puerto Rico, the U.S. Virgin Islands, Trinidad and Tobago, and Barbados. Early findings are published in the journal Ethnicity & Disease.
Shared Decision Making
In partnership with the Patient Revolution, Erica Spatz, MD, MHS, facilitates peer-to-peer sessions for women to think, feel, and talk about their cardiovascular health. Attendees participate in activities that help them consider important decisions such as diet exercise. This program is made possible with support from the Alpha Phi Foundation.
Approaches to Community Health
Project Access-New Haven (PA-NH) is a nonprofit organization dedicated to increasing access to medical care for uninsured patients. Yale physicians partner with patient navigators and community health workers to help underserved patients access timely medical care and connect with local resources to address health-related social needs.
See the results of one of our recent studies in Circulation: Cardiovascular Quality and Outcomes, "Use of Mobile Health Applications in Low-Income Populations A Prospective Study of Facilitators and Barriers."
See the specifics of on our active programs which identifies patients with social needs (housing; food; utilities; transportation), at the point of care, and connects them with a community health worker from PA-NH Racial and Ethnic Approaches to Community Health (REACH).