Why Hypertension?

Nearly one in three U.S. adults – 70 million people – has high blood pressure or hypertension, a major risk factor for heart disease, stroke, and kidney failure. Only about half of individuals with hypertension have their blood pressure under control. About 11 million of them don’t know their blood pressure is too high and are not receiving treatment to control it, even though most of these individuals have health insurance and visit a health care provider each year. That means potentially millions of people with uncontrolled hypertension are seen by clinicians but remain undiagnosed. While following best practices and providing the highest levels of care, providers can still have patients “hiding in plain sight” who are at risk for or have undiagnosed hypertension. Finding these patients and spreading the word about how other health care professionals can find them may help save lives. Medications and behavioral strategies are highly effective in reducing morbidity and mortality from hypertension (CDC, 2014).


What We Do

RCHC’s program on hypertension management includes shared clinical guidelines, clinical decision support tools, sharing of best practices, and quality improvement and population health support in the form of trainings.

RCHC health centers in Sonoma County are engaged in the Hearts of Sonoma County initiative, a cardiovascular disease risk reduction initiative of the Committee for Healthcare Improvement (CHI), a committee of Health Action. The goal of the initiative is to prevent heart attacks and strokes, a leading cause of death and disability in Sonoma County, through earlier detection and better management of hypertension and other cardiovascular disease risk factors.  Representatives from RCHC, West County Health Centers, Santa Rosa Community Health and Sonoma County Indian Health Project have been engaged in the initiative since May 2014. Alexander Valley Healthcare, Petaluma Health Center, Santa Rosa Community Health and West County Health Centers are sharing clinical data for this initiative.  Other primary care provider groups participating include Kaiser Permanente Medical Group of Santa Rosa, Sutter Medical Group of the Redwoods, and St. Joseph Medical Group.

Guidelines and Protocols

Clinical Decision Support

Promising Practices


Who We Serve

We serve the 13 participating health centers and over 185,000 health center patients from 5 counties: Marin, Mendocino, Napa, Sonoma, and Yolo.

Health Centers: Alexander Valley Healthcare, Anderson Valley Health Center, Coastal Health Alliance, CommuniCare Health Centers, Marin City Health and Wellness, Marin Community Clinics, OLE Health, Petaluma Health Center, Ritter Center, Santa Rosa Community Health, Sonoma Valley Community Health Center, West County Health Centers, and Winters Healthcare Foundation.


“This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H2QCS30258, Health Center Controlled Networks, for $1,500,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.”

Project Timeline

August 1, 2016 – July 31, 2019


The project team will use our four-point Evidence Based Care program to focus on the following measure.

Outcome Measures
Hypertension – Blood Pressure Control


Health Centers:

  • Alexander Valley Healthcare
  • Anderson Valley Health Center
  • Coastal Health Alliance
  • CommuniCare Health Centers
  • Marin City Health and Wellness
  • Marin Community Clinics
  • OLE Health
  • Petaluma Health Center
  • Ritter Center
  • Santa Rosa Community Health
  • Sonoma Valley Community Health Center
  • West County Health Centers
  • Winters Healthcare Foundation

Strategic Partners:

  • Health Resources and Services Administration (HRSA)
  • Sonoma County Health Action and the Committee for Healthcare Improvement


For more information, please contact Michelle Rosaschi.