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Rural Health Information Hub

Heartland OK

  • Need: To reduce rural Oklahoma patients' risks for heart disease and stroke.
  • Intervention: Heartland OK, which began in 5 rural counties, was a care coordination model.
  • Results: Using a team-based care model increased 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 2020 show that 14,407 Oklahomans died from cardiovascular disease.

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 attacks. The program then expanded to 20 counties.

Heartland OK worked to reduce patients' risk for heart disease and stroke through care coordination. The project, which brought together healthcare and public health, promoted 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 Million Hearts® initiative. Program expansion into other high-prevalence areas of the state was facilitated through CDC and ASTHO grant funding.

Services offered

To be referred to the Heartland OK program, patients had to 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 uncontrolled

A coordinated care team and healthcare providers in each participating county:

  • Applied ABCS of Heart Health to achieve maximum cross-cutting outcomes
  • Provided free blood pressure checks
  • Tracked patients' blood pressure readings
  • Worked with pharmacists to help patients adhere to medication plans
  • Collaborated with Cooperative Extension Service offices for referrals to their nutrition education programs

While the Heartland OK project as described has ended, one partner continues to educate on the C.H.I.L.L.I. protocol (a standardized blood pressure protocol) and refer to a team-based care model, in areas where the infrastructure is available. The team-based care group includes community pharmacists who provide medication therapy management, community health workers for connection to local organizations, and Cooperative Extension Services for nutrition counseling/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 continued 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).

Program coordinators have modified the original Heartland OK model for collaboration with the Oklahoma Primary Care Association, the Oklahoma Department of Mental Health, the state's two Colleges of Pharmacy, and the OK Foundation for Medical Quality. These partners are working to promote improved prevention and self-management of high blood pressure using a team-based care model for patients seen in rural healthcare sites. Panel management tools, dashboards, and referrals to community-based organizations are some of the workforce resources being utilized to improve care for patients with chronic conditions.


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.

To address the EHR concerns, partners 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 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 Information

Joyce Lopez, Program Manager for Prevention
Oklahoma State Department of Health, Chronic Disease Prevention Service

Cardiovascular disease
Care coordination
Networking and collaboration
Public health
Wellness, health promotion, and disease prevention

States served

Date added
October 31, 2016

Date updated or reviewed
November 18, 2022

Suggested citation: Rural Health Information Hub, 2022. Heartland OK [online]. Rural Health Information Hub. Available at: [Accessed 15 April 2024]

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.