We Heart Your Heart

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So you didn’t get chocolate or flowers on February 14? Your health centers still “heart” you. February marks National Heart Month and time to shine light on what the Community Health Center Network (CHCN) member centers are doing to keep the community’s tickers ticking. Health center patients face a sobering statistic: Their diabetes or heart disease mean they are two to four times more likely to have a heart attack or stroke. And about 65% of those individuals will die of these events (data from Kaiser Community Benefit).

For the past two years, patients who go to CHCN health centers get more attention to improve their heart health through PHASE – Preventing Heart Attacks and Strokes Every Day. As grantees of Kaiser Community Benefit’s PHASE program, we combine a low-cost, easy to use medication regimen and healthy lifestyle interventions for patients with high blood pressure.

Keeping a close eye on how patients are doing makes a difference. “Data is at the heart of it,” said Lifelong Medical Center provider Doug Frey at a recent PHASE gathering of clinics. Data plays an important role at every PHASE stage, from who participates to how provider teams set up and deliver care and monitor patient behavior. With analytics in hand, participating CHCN clinics aim to produce meaningful improvement in blood pressure management for more than 34,700 patients.

The results can be life-changing. People with diabetes are at increased risk for hypertension. If only 10% of patients with diabetes in America were started and maintained on the three drug regimen, 32,000 heart attacks and strokes each year would be prevented, resulting in more than $1 billion in health care savings annually (Archimedes Inc.).

After one year of focusing on collecting and reporting data, participating health centers now turn to using that information to make concrete changes at the clinic level. CHCN clinics convened to share what’s working for them, including how they:

– conduct outreach to follow up with patients who have uncontrolled hypertension

– manage and organize short patient follow up visits

– communicate effectively to patients about the importance of managing blood pressure

– involve more clinicians and staff as a team to boost coordination and, ultimately, patient success

In the coming year, CHCN will expand on the panel management foundation of PHASE by reaching more patients, improving care through deeper data analytics and monitoring whether patients are picking up their medications. The project is supported by Kaiser Permanente Northern California Community Benefits Programs.  CHCN also participates in a national campaign to reduce hearth health risks, Million Hearts.  The campaign aims to prevent a million heart attacks by 2017.


– Read more about PHASE here.