Why Heart Attacks and Strokes?

About 600,000 people in the United States die of heart disease every year—that’s one in every four deaths. With generous funding from Kaiser Permanente, Redwood Community Health Coalition (RCHC) is part of a national effort to help prevent heart attacks and strokes among people who are at greatest risk. Since developing PHASE in 2002, Kaiser Permanente has reduced the incidence of heart attacks and strokes among its members by more than 60%. Cardiovascular disease, including heart attacks and strokes, is the leading cause of death in our community.

PROGRAM

What We Do

PHASE is a population health management program to care for people with/at risk of cardiovascular disease using Kaiser Permanente’s evidence-based clinical protocol that, when followed, reduces cardiovascular disease. PHASE combines medications and lifestyle changes to provide a cost-effective treatment for people with existing heart disease and those at a risk for developing it. Successfully implementing the program requires coordination among care providers and reliable patient data management.

Clinical Guidelines and Protocols

Clinical Decision Support

Under Development

Promising Practices

Under Development

Trainings

RCHC Training Calendar

Interventions

As part of this grant, participating health centers are implementing the following interventions:

  • Shared clinical guidelines agreed to by RCHC Medical Directors/CMOs
  • RCHC developed toolkits for PHASE in coordination with participating health centers
  • Regular meetings with PHASE Champions and discussion of initiatives in peer network meetings
  • RCHC participation in Kaiser Permanente Learning Community and Convenings to share resources, new strategies and updates with health centers
  • RCHC templates for RN standardized procedures and monthly case conference webinars
  • Standardized CDS tools for PHASE
  • Health center staff participate in trainings offered at no cost by Kaiser Permanente and Support Team (motivational interviewing, panel management, health coaching, and more TBA)
  • RCHC develops regular PHASE reports for use by eCW health centers and provides training on the use and interpretation of reports
  • RCHC and CHCs collect data and assess performance quarterly

Who We Serve

Patients ages 18 and over with one or more of the following diagnoses are eligible for the program:

  • Clinical Atherosclerotic Cardiovascular Disease (ASCVD)
    • Abdominal Aortic Aneurysm (AAA), Peripheral Artery Disease (PAD), Cerebral Vascular Accident (CVA) /Transient Ischemic Attack (TIA), Coronary Artery Disease (CAD)
  • Diabetes (DM)

Funder

This project is funded by Kaiser Permanent Northern California Community Benefits Program.

Project Timeline

January 2017 – December 2019

Measures

Process Measures Outcome Measures
# of PHASE eligible patients identified % of patients prescribed a statin
# of patients with diagnosis of diabetes % of patients prescribed an ACE or ARB
# of patients with a diagnosis of ASCVD % of patients prescribed both a stain and an ACE or ARB
# of patients with a diagnosis of hypertension % of diabetic patients with BP controlled
# of trainings completed % of diabetic patients with HbA1c ≤ 9
% of patients with hypertension with BP controlled

PERFORMANCE/RESULTS

Wave 1: As of August 2016 RCHC health centers served approximately 26,000 patients diagnosed with hypertension.  Among the eight PHASE health centers, about 18,000 patients were diagnosed with hypertension. The eight health centers participating in PHASE have identified 8,074 PHASE patients at 22 sites for potential interventions as of October 2016.

RCHC baseline blood pressure control among hypertensive patients according to 2014 UDS data was 64% (excludes Sonoma County Indian Health Project).  RCHC’s goal was to increase blood pressure control rates among hypertensive patients by 3% in 2015 and 3% in 2016 to achieve 70% control.  2015 UDS data for all RCHC health centers in 2015 was 65%. As of October 31, 2016, the PHASE health centers reported 70% blood pressure control among hypertensives, which achieved our target of 70%.

Wave 2: Wave 2 of this project began in January 2017. Results of Wave 2 will be available in early 2018.

PROJECT PARTNERS

Health Centers:

  • Alliance Medical Center
  • Coastal Health Alliance
  • ComminiCare Health Centers
  • Marin Community Clinics
  • Petaluma Health Center
  • Santa Rosa Community Health Centers
  • Sonoma County Indian Health Project
  • West County Health Centers

Strategic Partners:

  • Kaiser Permanente Northern California Community Benefit Programs
  • UCSF’s Center for Excellence in Primary Care
  • Center for Care Innovations

Evaluation Assistance:

  • Center for Community Health and Evaluation

PROJECT CONTACT

For more information, please contact Michelle Rosaschi.

ALIGNMENT WITH OTHER INITIATIVES

  • HRSA HCCN Grant
  • Complex Care Initiative
  • Hearts of Sonoma County
  • RCCO
  • Partnership HealthPlan’s Quality Improvement Program (QIP)
  • RCHC’s Performance Improvement Program (PIP)
“We are excited to be part of the PHASE initiative,” said Dr. Danielle Oryn, RCHC’s Chief Medical Officer. “PHASE is effective because it helps keep treatment simple and affordable — it makes a world of difference by giving patients a simple plan to help stay healthy. Our community health centers are committed to improve access and the quality of care provided for underserved and uninsured people in our four county region and this grant gives us the resources to expand the PHASE program to serve approximately 13,000 patients who are diagnosed with diabetes or atherosclerotic cardiovascular disease (ASCVD).”

ADDITIONAL RESOURCES AND COMPANION DOCUMENTS