- Need: To reduce rural Oklahoma patients' risks for heart disease and stroke.
- Intervention: Heartland OK, which began in 5 rural counties, is a care coordination model.
- Results: Using a team-based care model increases patients' ability to reduce their blood pressure or achieve blood pressure control.
Heart disease is the leading cause of death for
Oklahomans. Oklahoma State Department of Health data from
2018 show that inpatient costs related to combined high
blood pressure and cerebrovascular disease discharges
exceed $4.32 billion in medical expenditures.
Heartland OK was a five-county pilot program serving a
part of rural Oklahoma with the highest percentage of
adults who have a history of coronary heart disease or
heart attack. The program has expanded to 20 counties.
Heartland OK works to reduce patients' risk for heart
disease and stroke through care coordination. The
project, which brings together healthcare and public
health, promotes the
ABCS of Heart Health:
- Aspirin as directed by your healthcare professional
- Blood pressure control
- Cholesterol management
- Smoking cessation
Heartland OK was initially funded by the Association of State and
Territorial Health Officials (ASTHO) as part of the
Hearts® initiative. Program expansion into other
high-prevalence areas of the state is facilitated through
CDC and ASTHO grant funding.
To be referred to the Heartland OK program, patients must
meet the following criteria:
- 18-85 years old
- Newly diagnosed/placed on hypertension medications OR
- Previously diagnosed/placed on
hypertension medications but condition is still
A coordinated care team and healthcare providers in each
- Apply ABCS of Heart Health to achieve maximum
- Provide free blood pressure checks
- Track patients' blood pressure readings
- Work with pharmacists to help patients adhere to
- Collaborate with Cooperative Extension Service
offices for referrals to their nutrition education
In the original ASTHO project, 32 patients were referred
to the program, 10 of whom actively participated. Within
90 days of being enrolled, 25% of participants met their
hypertension goals. Patients often continue with
Heartland OK even after meeting blood pressure goals.
Since the original project in 2015, the Oklahoma State
Department of Health worked with the Choctaw Nation
through another ASTHO-funded opportunity to implement a
pharmacy-based model of Heartland OK. Pharmacists within
Choctaw Nation received 88 referrals from health system
providers and provided 160 patient visits, with 67
patients reducing their blood pressure (42 of whom
Smaller versions of Heartland OK are being offered in
local county health departments with similar successes
being reported. There are plans to expand Heartland OK to
additional counties through collaborative efforts with
the Oklahoma Primary Care Association and the Oklahoma
Department of Mental Health and Substance Abuse Services
Behavioral Health Homes, where primary care is integrated
with behavioral health services, but these plans are put
on hold due to the COVID-19 pandemic.
Researchers used a quality improvement approach in
developing the Heartland OK model and identified gaps in
two critical areas:
- Inconsistent methods for collecting blood pressure
- Electronic health records (EHR)
incapable of running panel management reports
To address the inconsistent methods, partners developed
and adopted the C.H.I.L.L.I. protocol, a standardized
blood pressure protocol.
To address the EHR concerns, researchers conducted three
visits each to 25 providers and trained them to run panel
management reports specific to NQF 18. This process
determined that only 30% of the providers (23 clinics)
located in the five pilot counties had an EHR capable of
running panel management reports. As a result, clinic
workflow processes were developed to facilitate
consistent delivery of care.
Project coordinators also recommend the following:
- Communicate among all stakeholders and share
resources to achieve a common goal.
- Create a process that is patient-centered and
efficient for providers.
- Allow time for the process to unfold. Establishing
collaborative relationships among community members takes
time and may transition through multiple stages of group
Joyce Lopez, Program Manager for Prevention
Oklahoma State Department of Health, Center for Chronic Disease Prevention and Health Promotion
Networking and collaboration
Wellness, health promotion, and disease prevention
October 31, 2016
Date updated or reviewed
November 3, 2021
Suggested citation: Rural Health Information Hub,
Heartland OK [online]. Rural Health Information Hub. Available at:
[Accessed 21 May 2022]
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.