Transforming Hypertension Care in Primary Care Practices: Equity and Community Collaboration in McKeesport

Funder: Merck Foundation, as part of its Collaborative for Equity in Cardiac Care Initiative

This initiative aims to improve hypertension care for underserved populations in McKeesport, PA and the surrounding 
Mon Valley area by integrating Community Health Workers (CHWs) into 25 UPMC-owned primary care practices.
It aims to address social determinants of health and enhance team-based, person-centered care to reduce disparities
in cardiovascular outcomes.

Funding Amount: $1.75 million over 5 years

Initiative Duration: October 1, 2025 – September 30, 2030

Initiative Collaborators: UPMC Center for High-Value Health Care, UPMC Center for Social Impact, UPMC for You,
UPMC-owned primary care practice (PCP) sites in McKeesport, PA and the surrounding Mon Valley area,
and Familylinks

Initiative Location: 25 UPMC-owned PCP sites across McKeesport, Pennsylvania and the surrounding Mon Valley area 

Background

UPMC Center for High-Value Health Care was one of 11 non-profit health care and public health organizations nationwide selected and awarded funding by the Merck Foundation to develop and implement innovative, comprehensive programs for cardiovascular disease management through the Foundation’s new Collaborative for Equity in Cardiac Care initiative.

Healthcare challenge

Hypertension is a leading modifiable risk factor for cardiovascular disease[1]and is compounded by poverty, limited access to care, and social barriers such as transportation and food insecurity[2]. McKeesport and the surrounding Mon Valley area face high rates of uncontrolled hypertension

Goals

UPMC Center for High-Value Health Care aims to serve our community by facilitating access to outstanding care and enhancing and shaping our health system through supporting clinical and technological innovation, program evaluation, education, and efforts to sustain and scale what works. This initiative aims to foster sustainable, team-based hypertension care that is responsive to the needs and priorities of McKeesport’s and the surrounding Mon Valley area’s underserved populations.

Implementation Approach

The initiative will serve adults with uncontrolled hypertension, with a particular focus on underserved groups who experience disproportionately poor cardiovascular outcomes due to systemic barriers in access to care and social determinants of health. Collaborators will implement a multi-pronged, evidence-based approach that integrates clinical best practices with community-based support, including:

  • Integrating Community Health Workers (CHWs) into primary care teams. CHWs will offer culturally responsive outreach, education, and navigation support to patients, helping address unmet social needs such as transportation, food insecurity, and digital literacy.
  • Leveraging UPMC’s electronic health record (EHR) infrastructure to support consistent, protocol-driven hypertension management.
  • Conducting training for providers and CHWs. Providers will receive continuing education focused on collaborative communication and CHW integration, while CHWs will be trained in hypertension care, behavioral change strategies, and use of digital tools to support patient engagement.
  • Utilizing a phased rollout to onboard 25 UPMC primary care practices over three years allowing for iteration and refinement of workflows.
  • Convening and engaging a Community Advisory Board (CAB)—comprising patients, CHWs, local community-based organizations, providers, and payer representatives—to guide implementation, ensure community alignment, and co-develop strategies for sustainability and scale.
  • Evaluating implementation using a mixed-methods approach, combining clinical metrics (e.g., blood pressure control rates) with patient-reported outcomes such as care satisfaction, trust, and quality of life.

 

1 Couch CA, Mascarenhas R, Stierman B, Fryar C. (2025 September). Prevalence of Cardiovascular Disease Risk Factors in Adults: United States, August 2021–August 2023. NCHS Data Brief No. 540. Retrieved September 19, 2025 from  https://www.cdc.gov/nchs/products/databriefs/db540.htm

2 Son H, Zhang D, Shen Y, Jaysing A, Zhang J, Chen Z, Mu L, Liu J, Rajbhandari-Thapa J, Li Y, Pagán JA. Social Determinants of Cardiovascular Health: A Longitudinal Analysis of Cardiovascular Disease Mortality in US Counties From 2009 to 2018. J Am Heart Assoc. 2023 Jan 17;12(2):e026940. doi: 10.1161/JAHA.122.026940. Epub 2023 Jan 10. PMID: 36625296; PMCID: PMC9939060.