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.
Lifestyle changes are measured in the following ways: BMI Screening & Follow-up, Depression Screening & Follow-up, and Tobacco Screening & Follow-up. Health centers provide follow-ups to assist patients make recommended healthy changes.
Guidelines and Protocols
To view the protocols listed below, click here:
- Standardized Procedure for Blood Pressure Management
- Standardized Procedure for Management of Type 2 Diabetes
- Use of Aspirin for Management of Patients at High Risk for Cardiovascular Events
- Use of Angiotensin-converting-enzyme Inhibitors and Angiotensin Receptor Antagonists for Management of Patients at High Risk for Cardiovascular Events
- Use of Statins for Management of Patients at High Risk for Cardiovascular Events
Clinical Decision Support
To access promising practices related to PHASE, such as hypertension, diabetes, and lifestyle screenings, click here.
As part of this grant, participating health centers are implementing the following interventions:
- Shared clinical guidelines agreed to by RCHC Medical Directors/CMOs
- 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 case conference webinars
- Standardized CDS tools for PHASE
- Health center staff participate in trainings offered by Kaiser Permanente and Support Team at no cost to them (e.g. motivational interviewing, panel management, health coaching, and more)
- RCHC develops regular PHASE reports for use by eCW health centers and provides training on the use and interpretation of reports
- RCHC and community health enters 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)
This project is funded by Kaiser Permanente Northern California Community Benefits Program.
January 2017 – December 2019
The project team will use our four-point Evidence Based Care framework to focus on the following 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|
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 2020.
- Alliance Medical Center
- Coastal Health Alliance
- CommuniCare Health Centers
- Marin Community Clinics
- Petaluma Health Center
- Santa Rosa Community Health
- Sonoma County Indian Health Project
- West County Health Centers
- Kaiser Permanente Northern California Community Benefit Programs
- UCSF’s Center for Excellence in Primary Care
- Center for Care Innovations
- Center for Community Health and Evaluation
For more information, please contact Kelly Bond.
ALIGNMENT WITH OTHER INITIATIVES
- Complex Care Initiative
- Hearts of Sonoma County
- HRSA Health Center Controlled Network (HCCN) Grant
- NACHC Million Hearts Statin Therapy Grant
- 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
- Center for Care Innovations PHASE updates
- PHASE Convening Presentation from June 2018: It’s Up to Us/Hearts of Sonoma County by Bo Greaves, MD
- PHASE Convening – Toward Equity in Hypertension Care November 2018: Event Materials & Presentation Slides
- New to PHASE? PHASE Onboarding Playbook
- RCHC Cardiovascular Health Initiative: Informational Presentation Slides
- Population Health Resources
- Health Coaching Curriculum
- Panel Management
- Project Management Tools
For PHASE reporting requirements and instructions, click here and go to the data reporting section on PHASE.