ARCHI, convened several Atlanta-area health systems (Grady Health System, Kaiser Permanente of Georgia, WellStar Health System, Piedmont Health System and Saint Joseph’s Mercy Care) in a collaborative effort to focus on improving hypertension and diabetes care management in metro Atlanta by utilizing process improvement strategies and incorporating evidence-based interventions. Recognizing the disproportionate rates of high blood pressure and diabetes for Metro Atlanta residents, ARCHI was contracted by the Georgia Department of Public Health to increase the number of organizations trained to facilitate the Georgia Healthy Heart Ambassador Blood Pressure Self-Monitoring Program.

Through the ARCHI-led Community Resource Hubs at Grady Health System and Saint Joseph’s Mercy Care, community health workers identify patients with high blood pressure, diabetes risk, and social determinant of health-related needs. Community health workers provide health coaching and linkage to Community Resource Hub partners and local agencies for housing, employment, food, transportation, social services, and benefit enrollment. In an effort to reduce the barrier to accessing these services, ARCHI also administers a support fund that will provide transportation resources. As patients address social determinants of health and their living situations improve, ARCHI hopes to see patients’ chronic conditions improve.

Health Systems Transformation

Organizational & Backbone Support