- 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.
According to 2017 CDC data, heart disease is the leading cause of death for Oklahomans, with 10,772 deaths attributed to heart disease that year. Oklahoma State Department of Health data from 2016 show that inpatient costs related to combined high blood pressure and cerebrovascular disease discharges exceed $925 million.
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
Heartland OK was initially funded by the Association of State and Territorial Health Officials (ASTHO) as part of the Million 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
A coordinated care team and healthcare providers in each participating county:
- Apply ABCS of Heart Health to achieve maximum crosscutting outcomes
- Provide free blood pressure checks
- Track patients' blood pressure readings
- Work with pharmacists to help patients adhere to medication plans
- Arrange for patients to consult with dietitians about basic nutrition guidelines
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 achieved control).
Smaller versions of Heartland OK are being offered in local county health departments with similar successes being reported. Heartland OK will be expanded 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.
Researchers used a quality improvement approach in developing the Heartland OK model and identified gaps in two critical areas:
- Inconsistent methods for collecting blood pressures
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 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 formation.
Contact InformationJoyce 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 25, 2019
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.