For Mattapan residents, a new effort is bringing care to their doorsteps.

The initiative — a collaboration between Boston Medical Center, Mass General Brigham and the Mattapan Community Health Center — aims to address long-standing disparities in heart disease and diabetes.

“Mattapan has the highest heart disease mortality rate in Boston,” said Dr. Elsie Taveras, executive director of Mass General Hospital’s Kraft Center for Community Health. “That’s not just a statistic, right? That’s a call to action and a call to act differently.”

The program works with cohorts of Mattapan residents for six-month periods and connects them to additional ways to track and care for their blood pressure and diabetes. It also provides wrap-around supports that organizers say make it easier for participants to focus on their health.

To be eligible, participants must be Mattapan residents living in the 02126 ZIP Code, primary care patients at one of the three health care providers and must have one of the targeted conditions.

According to data released by the Boston Public Health Commission in 2023, 40% of Mattapan adults had hypertension, the highest of any neighborhood. It also had 156 hospitalizations due to heart disease per 10,000 residents and 157 deaths due to heart disease per 100,000 residents — the highest of any neighborhood in all three categories.

When it came to city data on diabetes, Mattapan also ranked highest for hospitalizations and mortality due to the disease. Only Roxbury had more tracked cases of diabetes, by a 10th of a percent.

Across the city in recent years, efforts to address health disparities have increasingly come into focus not just on specific health conditions, but the broader factors that fuel those gaps.

Public health experts call those out-of-hospital factors — things like access to healthy food, housing or employment — social risk factors or social determinants of health.

At the HEART of Communities program, clinical care — like learning medication management and how to use glucose monitors or blood pressure cuffs — is paired with efforts around job placement, mentorship, access to healthy foods and cooking programs. The initiative also integrates behavioral health care and works to reduce isolation through group programming.

Leaders of the program said that often, those factors can really shift who accesses care and how.

Disparities like the ones identified in Mattapan are generally a symptom of broader conditions, like when patients must ration resources to pay for rent or food before medical care, said Dr. Thea James, BMC vice president of mission and co-executive director of the hospital system’s Health Equity Accelerator.

“When you see clinical outcomes like that, they’re generally rooted in economics,” James said.

It’s an effort that goes hand-inhand with other municipal initiatives, like the city of Boston’s Live Long and Well Agenda launched by the Public Health Commission in 2024.

The Live Long and Well Agenda is aimed at closing long-standing life expectancy gaps in the city, with a particular focus on heart disease and diabetes, preventable cancers and overdose deaths — conditions that disproportionately affect communities of color and that the commission has identified as the leading causes of premature death in those communities.

In August, the city announced its first group of four community coalitions it is funding through a $5 million investment from the Atrius Health Equity Foundation to address economic mobility as a social determinant of health.

For the HEART of Communities initiative, while two of the organizations leading the program are based in or around downtown Boston, the program is truly rooted in Mattapan, Taveras said.

The clinical components of the program are hosted at the Mattapan Health Center in Mattapan Square and the culinary education lessons take place in the health center’s teaching kitchen. Access to healthy ingredients is provided through a mobile produce market from Mass General Brigham, which will make the trip to the neighborhood. Efforts to connect participants to employment opportunities are run through local organizations.

“What we have built is a single, community-informed experience, delivered steps away from where people live,” Taveras said. “That’s really important. It should be what people should expect.”

That local grounding comes from the design process, James said, which involved community meetings with patients and stakeholders to identify what a better model of health care delivery might look like.

“They often don’t fit into health care systems that are not generally designed for alternative expectations,” James said. “They’re designed for perfect scenarios of patients who use them, and the majority of our patients do not have perfect scenarios.”

The organizations leading the effort touted the innovation they said it brings.

“I think it’s very, very straightforward, but it’s not the way that medicine generally thinks,” James said.

Guale Valdez, CEO of the Mattapan Community Health Center, said that kind of innovation is key to how the health center operates.

“One of the things I’ve always believed in is that we, as a health center, have an obligation to always look for better ways to provide care,” Valdez said. “We always have to be innovative, and this fell right in line with that.”

Key to that work, they said, is the partnership between the three groups, which has brought expanded resources to a shared vision.

Taveras said she has seen an increase in cross-institutional collaboration in the past five years, especially since the COVID-19 pandemic.

“[We] have realized that we could go further and be so much more impactful when we leave at the door our affiliations and truly center people and communities,” she said. “That’s what this is an example of.”

Valdez sees the role of the center as bringing Mattapan perspectives to the conversation and says the partnership has opened new doors.

“To focus on innovation on our own is one thing — we do quite well with that, by the way,” Valdez said, “but to focus on innovation with the resources and the talent that all of our organizations bring together? That’s never been done before.”

The roots of this initiative date back two years, well before the current federal administration and the cuts to health care. James said she thinks the work has a particular importance in a time where health and particularly health equity efforts are facing pressure.

“Now there’s a great deal more pressure, or maybe even a pressure that didn’t exist previously, but it doesn’t stop us from persevering and doing what needs to be done,” James said.

But Valdez also pointed out that the disparities the effort aims to address have been around for years and need to be addressed regardless of who is in office.

“There have been challenges in this environment for the longest time — not just with this administration, but there’s always been challenges in how care is delivered,” he said.

The program is still in its early stages — something leaders from all three organizations were quick to point out — but preliminary results from the first cohort, which began in the spring and has completed its six-month follow-up, seem promising. The team has started enrolling the second cohort.

While they said it’s too early to make promises, they could envision the kind of program they’ve been operating spreading to other neighborhoods and expanding to address other conditions.

“Our goal is to learn from this first demonstration program in Mattapan — to learn what works for who and how,” Taveras said. “How do we iterate to then bring this community-informed model to other neighborhoods in Boston and to piggyback onto what we are doing, even in Mattapan, other conditions that are also important and of high burden.”

She said those other issues might include things like maternal and infant mortality or preventable cancers.

James said she could envision a goal of expanding the model of care to other neighborhoods and that a look at the disparities tracked in the Boston Public Health Commission’s data reveal “there’s plenty of opportunities.”

That sort of expansion could bring the model of community design out to the rest of the city, something she said should continue to be top of mind.

“Honestly, anything you’re planning to do with patients should always begin with stakeholders, with the community itself, and community members and patients in the area that you’re going to work with,” James said.