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 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.


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

Promising Practices

To access promising practices related to PHASE, such as hypertension, diabetes, and lifestyle screenings, click here.


RCHC Training Calendar


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 centers 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 The Kaiser Foundation Hospital Fund for Community Benefit Programs at the East Bay Community Foundation.

Project Timeline

January 1, 2020 – March 31st, 2021


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 with hypertension with BP controlled
# of patients with diagnosis of diabetes % of patients with diabetes with BP controlled
# of patients with a diagnosis of ASCVD % of patients with diabetes with HbA1c > 9
# of patients with a diagnosis of hypertension % patients with BMI, depression, and tobacco screening and follow-up
# of trainings completed % of patients prescribed a statin
%  uninsured patients with diabetes


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%.


Health Centers:

  • Alexander Valley Healthcare
  • Alliance Medical Center
  • Coastal Health Alliance
  • CommuniCare Health Centers
  • Marin City Health and Wellness Center
  • Marin Community Clinics
  • Petaluma Health Center
  • Ritter Center
  • Santa Rosa Community Health
  • Sonoma County Indian Health Project
  • West County Health Centers

Strategic Partners:

  • Kaiser Permanente Northern California Community Benefit Programs
  • The Kaiser Foundation Hospital Fund for Community Benefit Programs at the East Bay Community Foundation
  • UCSF’s Center for Excellence in Primary Care
  • Center for Care Innovations

Evaluation Assistance:

  • Center for Community Health and Evaluation


For more information, please contact Kelly Bond.


  • 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)


    • Center for Care Innovations PHASE updates