Improving Heart Health in our Neighborhood

Improving Heart Health in our Neighborhood
Daniel Mota, MD, MHS, Director of Quality Improvement, Care Coordination & Value-Based Care, leads Dimock’s Cardiometabolic Clinic in providing integrated, whole-person care to support patients’ long-term health and wellness.

Dimock’s Cardiometabolic Clinic Takes a Whole-Person Approach to Wellness

The heart does more than just pump blood—it’s vitally connected to the health of our entire body. Despite this, many adults live with undiagnosed or unmanaged heart conditions.

Because of this harsh reality, heart disease remains one of the leading threats to our health, shortening and claiming the lives of so many Americans.

  • Heart disease is the leading cause of death among Americans.1
  • Someone in the U.S. dies of cardiovascular disease every 34 seconds.2

That’s why The Dimock Center is committed to supporting our neighbors in managing heart-related health conditions through our Cardiometabolic Clinic. 

This clinic is about more than only improving quality of life—it’s about ensuring that our Dimock friends, families, and neighbors can live long, healthy lives.

 “We don’t want to ignore the fact that we have challenges. We do want to take these opportunities to remind ourselves that there are things that we can do when we come together as a community and bring a positive energy to solving problems.” Dr. Charles Anderson, President & Chief Executive Officer

 “We don’t want to ignore the fact that we have challenges. We do want to take these opportunities to remind ourselves that there are things that we can do when we come together as a community and bring a positive energy to solving problems.” Dr. Charles Anderson, President & Chief Executive Officer

Furthering the well-being of our community starts with identifying the key factors driving poor heart health in the Roxbury community, such as the challenges our neighbors face in accessing care, understanding their conditions, and sticking to treatment plans. At Dimock, we are partnering with our patients to help tackle these barriers. 

Dimock’s innovative approach starts with identifying patients at the greatest risk for high blood pressure, diabetes, and high cholesterol.

Our Quality Improvement team refers these patients to the Cardiometabolic Clinic’s Care Coordinator, who then reaches out to patients due for follow-up visits, schedules appointments, and checks in to see if they’re keeping up with their medications or facing any challenges in taking them regularly.

The Cardiometabolic Care Coordinator also relies on other care management staff to evaluate obstacles patients face in attending appointments (such as transportation) and to monitor their blood pressure measurements and blood sugar levels. This personalized support and outreach—delivered both by phone and in person—takes place between primary care visits. It’s one of Dimock’s unique strategies to ensure patients effectively manage their conditions and maintain their health for the long term.  

“The support provided by our clinic significantly enhances the quality of life for our patients. Through compassionate and comprehensive care, we ensure every patient receives the necessary attention and support.” Joanna Figueroa, Cardiometabolic Care Coordinator

“The support provided by our clinic significantly enhances the quality of life for our patients. Through compassionate and comprehensive care, we ensure every patient receives the necessary attention and support.” Joanna Figueroa, Cardiometabolic Care Coordinator

At Dimock, we understand that heart health is connected to so many other vital systems in your body, as well as your social and emotional health. That’s why patients of the Cardiometabolic Clinic can access health and behavioral care services, all on our Roxbury campus. 

Our whole-person approach to cardiometabolic health is helping individuals in our community live healthier, longer lives. By supporting every aspect of our patients’ well-being, we are striving to build a future where every heart beats strong.