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.

About the Bernard J. Tyson National Award for Pursuit of Healthcare Equity: Bernard J. Tyson, the late Chairman and Chief Executive Officer of Kaiser Permanente, worked tirelessly to address the health care disparities that plague the U.S. health care system. To honor his memory, The Joint Commission and Kaiser Permanente established The Bernard J. Tyson National Award for Pursuit of Healthcare Equity. This annual award recognizes health care organizations that directly deliver health care and their partners that led initiatives that achieved a measurable, sustained reduction in one or more health care disparities.