Why Heart Attacks and Strokes?
- More than 800,000 people in the United States die from cardiovascular disease (CVD) every year*.
- More than 1.5 million people in the United States suffer from heart attacks and strokes every year*.
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
- PHASE Algorithm
- 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
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 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.
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|
Health Center Participation
- 2012-2014 grant cycle: four health centers participated
- 2015-2016 grant cycle: four health centers participated
- 2017-2019 grant cycle: eight health centers participated
- 2020-2021 grant cycle: eleven health centers are participating
As of January 2020, RCHC PHASE health centers served approximately 22,300 patients diagnosed with hypertension. This is an increase in patients from approximately 15,951 in January 2017. These patients had a hypertension control rate of 67.8% as of March 31, 2017. By December 31, 2019, the rate of control had increased to 74.3%.
RCHC PHASE health centers saw an increase in diabetes control (A1c <9%) over the 2017-2019 grant period, from 66.2% in 2017 to 70.7% in 2019. Self-reported building block clinic assessments completed by RCHC PHASE health centers in 2019 showed improvement in all five building blocks from the 2017 assessment (overall score of 8.2) to the 2019 assessment (overall score of 9). The building block with the greatest improvement was “Data-Based Decision Making”, from 8.1 in 2017 to 9.6 in 2019. The 2019 assessment also included a new building block, “Patient-Team Partnership”, which scored 7.6 overall. These assessments help RCHC focus resources and trainings for health centers, and gauge how health centers improve over time.
- 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
- 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
- Center for Community Health and Evaluation
For more information, please contact Michelle Rosaschi.
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)
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.