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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, 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 Million Hearts® initiative. Program expansion into other high-prevalence areas of the state is facilitated through CDC and ASTHO grant funding.

Services offered

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 uncontrolled

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
  • Collaborate with Cooperative Extension Service offices for referrals to their nutrition education programs


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. 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 formation.

Contact Information

Joyce Lopez, Program Manager for Prevention
Oklahoma State Department of Health, Center for Chronic Disease Prevention and Health Promotion

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 3, 2021

Suggested citation: Rural Health Information Hub, 2021. Heartland OK [online]. Rural Health Information Hub. Available at: [Accessed 25 September 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.