2025 Tyson Award Recipient Cone Health - Bridging Disparities in Hypertension Control for Black/African American Patients
Cone Health, a not-for-profit healthcare network serving North Carolina, reported that in 2023, only 66% of Black patients with a Cone Health primary care provider had controlled hypertension, compared to 75.6% in other populations, prompting a systemwide call to action. To close this gap, Cone Health launched a multidisciplinary, team-based care model that targeted systemic barriers such as medication access, cost, transportation, and health literacy—factors that disproportionately affect underserved communities. The program integrated physicians, pharmacists, and social workers to deliver culturally responsive education, optimize medication, and address social determinants of health.
Their efforts yielded remarkable success among the study population, many of whom initially saw significantly worse blood pressure control than the patient population at large. Study participants also experienced conditions like diabetes at high rates and faced significant barriers based on their social determinants of health. Cone Health’s efforts yielded remarkable success among the initial study population. Between October 2023 and May 2024:
- Among all patients, blood pressure control improved by 3.1 percentage points from 69.8% to 72.9%.
- Among Black patients, blood pressure control improved by 5.6 percentage points from 64.9% to 70.5%, with an average blood pressure reduction of –15.6/–6.1 mmHg.
- In patients with high social determinants of health risk, control improved from 8.8% to 69.2%.
- Medication access barriers dropped from 26% to 10%.
- Cost-related non-adherence fell from 24% to 8%.
To ensure sustainability, Cone Health embedded real-time dashboards, electronic health record alerts, and quarterly care coordination reviews into clinical workflows. Staff received ongoing training, and patient feedback was continuously gathered to refine the model. The initiative also leveraged AI-driven behavior nudging tools to support long-term adherence.
The model was later scaled to additional clinics and integrated into Cone Health’s broader “CATCH 5 in 5” initiative, which aims to reduce life expectancy disparities by five years over five years. The program’s tools and workflows have been shared across the system and adapted by external partners, demonstrating its potential for widespread replication.
The award panel was impressed by the comprehensive systemwide change, patient-centered design, and strong community and patient engagement.
Congratulations to Cone Health for their comprehensive, equity-driven, and impactful approach to improve care and reduce disparities for their patients.
Read more within the 2025 Awardee application
2024 Tyson Award Recipient
Zuckerberg San Francisco General Hospital and Trauma Center: Reducing Racial Disparities for African American Patients with Heart Failure
The Joint Commission and Kaiser Permanente have named Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) as the recipient of the 2024 Bernard J. Tyson National Award for Pursuit of Healthcare Equity for their initiative: Reducing Racial Disparities for African American Patients with Heart Failure.
This prestigious award, established in honor of late Kaiser Permanente Chair and CEO Bernard J. Tyson, honors a healthcare organization for its efforts that achieved a measurable, sustained reduction in one or more healthcare disparities.
Clinicians at ZSFG identified heart failure as a leading cause of hospitalization for Black/African American patients. Additionally, many heart failure patients who were readmitted also had co-occurring substance use disorders.
ZSFG implemented two primary interventions:
- To better manage care for patients with heart failure, ZSFG integrated digital tools into the clinical workflow, including an electronic health record-based decision support tool and a real-time dashboard.
- To address comorbidities, ZSFG created an addiction medicine/cardiology co-management clinic. This allowed clinicians in primary care, cardiology, social medicine, addiction medicine, and palliative care to collaborate in caring for patients at highest risk for heart failure.
Congratulations to the team at Zuckerberg San Francisco General Hospital and Trauma Center for their impressive equity and quality improvement work as well as improved outcomes for their patients!
2024 Tyson Awardee’s Application Summary Zuckerberg San Francisco General Hospital and Trauma Center - Reducing Racial Disparities for African American Patients with Heart Failure
2024 Tyson Award Top Finalists
2024 Tyson Award All Applicants
2023 Tyson Award Recipient
University of Chicago Medicine Systematic Treatment and Management of Postpartum Hypertension (STAMPP-HTN)
Systematic Treatment and Management of Postpartum Hypertension (STAMPP-HTN) is a series of interventions to improve postpartum care for women with hypertensive disorders of pregnancy (HDP) implemented at the University of Chicago Medicine, a tertiary urban care center with a predominantly Black and publicly insured patient population.
The STAMPP-HTM team implemented an intervention bundle, including:
- education to all patients and care providers
- updated clinic protocols for patients
- distribution of a STAMPP-HTN kit, which included a blood pressure monitor, instructions, warning signs, and a preeclampsia alert wrist bracelet, to all postpartum patients with an HDP
- consistent scheduling of follow-up appointments before discharge
- standardized protocols and workflows for the management of patients after hospital discharge
The initiative was implemented in phases to deploy additional interventions and further improvement over time. After the intervention bundle, telehealth visits and remote patient monitoring were made available.
These interventions significantly improved patient visit adherence and reduced the disparities between patient populations.
Results
At baseline, the rate of postpartum follow-up visit attendance within six weeks for a blood pressure check was:
- 30% for Black patients
- 53.5% for white patients
Once the intervention bundle was fully implemented, the rate of postpartum follow-up visit attendance improved to:
- 33.5% for Black patients
- 59.4% for white patients
Later, providing telehealth options (and continued use of the intervention bundle) further improved the rate of postpartum follow-up visit attendance to:
- 76.3% for Black patients
- 76.7% for white patients
This left only a 0.4% disparity between Black and white patients.
The final intervention, the implementation of a remote patient monitoring program, further improved the rate of postpartum follow-up visit attendance to 83.1%, with similar rates among Black and white patients, eliminating the disparity between Black and white patients.
Patients’ clinical outcomes also improved. After implementation, fewer patients experienced a blood pressure of 140/90 or higher at the first postpartum blood pressure check when compared with preintervention (18.5% vs. 39.1%, P<.004). The effect size did not differ by race.
Panel Notes
The Tyson Award panel was impressed by the comprehensive, multi-level bundle of interventions, engagement across departments, convenient ways patients could access information and care, and patient education and empowerment. They noted that the disparity was approached in a holistic way.
Use of telehealth and remote patient monitoring, in addition to the clinical interventions, resulted in improvement across all populations, but most significantly, decreased the disparity for Black patients. The panel acknowledged the significant clinical relevance, noting the size and impact of the improvement was remarkable.
The panel perceived that postpartum hypertension is a very specific and actionable clinical area and the UChicago Medicine team addressed the disparity in a way that could be replicable – like a roadmap – for other organizations to implement similar interventions to reduce disparities for their postpartum hypertensive patients.
University of Chicago Medicine: Systematic Treatment and Management of Postpartum Hypertension (STAMPP-HTN)
2022 Tyson Award Recipients
NYC Health + Hospitals - In 2019, NYC Health + Hospitals, the largest municipal healthcare system in the nation, launched NYC Care, a citywide healthcare access program for New Yorkers who are ineligible for or cannot afford health insurance, including undocumented individuals. The city estimates that there over 400,000 undocumented immigrants who are uninsured and are more likely to forego essential primary and preventive care.
NYC Care provides access to low or no-cost primary and specialty care, prescription medicines, member materials in multiple languages, a membership card, and a 24-hour customer service line. The program leverages a system-wide integrated electronic medical record system, e-referral system, and telehealth platforms to provide high-quality, coordinated care to NYC Care members.
This initiative:
- Enrolled more than 100,000 members, who made 264,976 primary care visits and 227,481 specialty visits by February 2022.
- Improved clinical outcomes: After six months of enrollment, 51% of enrollees with diabetes had improved hemoglobin A1C, and 68% of enrollees with hypertension had improved blood pressure.
See below link to learn more about their initiative, strategies employed, interventions implemented, and key take-aways for replicability.
NYC Health + Hospitals - Making Healthcare a Human Right: Expanding Access to Healthcare to Undocumented New Yorkers
Texas Children’s Pavilion for Women - In March 2019, Texas Children’s Pavilion for Women began stratifying data by race and ethnicity and determined that non-Hispanic Black women had the highest rates of severe maternal morbidity from hemorrhage (SMM-H). A gap analysis identified interventions to reduce morbidity from hemorrhage for all pregnant patients, including hemorrhage risk assessment, drills, active management of the third stage of labor, and a multidisciplinary review of serious hemorrhages to identify systematic issues. A health equity lens was applied to these efforts and Black/African American race was added as a medium risk factor for hemorrhage to help address implicit bias and accelerate healthcare team response.
Prior to implementation of these strategies, there was a statistically significant difference between Black and White women for SMM-H rates (p<0.001). This disparity was no longer significant post-intervention (p=0.138), and the rate of SMM-H in Black women decreased significantly from 45.5% to 31.6% (p=0.011). This team’s initiative was described In further detail in Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity which was published in BMJ Quality & Safety.
See below link to learn more about their initiative, strategies employed, interventions implemented, and key take-aways for replicability.
Texas Children’s Pavilion for Women - Quality Improvement Initiatives on Decreasing Racial Disparities in Maternal Morbidity
2021 Tyson Award Recipient
A UMass Memorial Health team identified and addressed disparities in adherence to well-child visits and guided their initiative with robust and ongoing use of data stratified by race, ethnicity, and language.
The multidisciplinary team interviewed external and internal stakeholders, patients and families. Barriers to adherence for well-child visits identified included transportation, language and scheduling. To improve accessibility and adherence to regular well-child visits, multiple strategies to overcome these barriers were implemented:
- Conducting well-child visits during acute care appointments
- Scheduling the next visit at the time of the current visit
- Providing patients and their families with an information sheet highlighting the importance of preventive care visits
- Implementing an improved reminder system
- Making telehealth appointments available
- Arranging transportation
- Actively reaching out to patients who canceled or were “no-shows” for their visits to reschedule
- Creating a well-child tip sheet to help measure success
In just nine months during the COVID-19 pandemic, adherence to child well-visits among Latino pediatric patients rose from 64 percent at baseline to 76 percent; among Black children, adherence improved from 59 percent to 75 percent.
See below link to learn more about their initiative, strategies employed, interventions implemented, and key take-aways for replicability.
UMass Memorial Health - Prioritizing Child Health: Promoting Adherence to Well-Child Visits
