- 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
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
Hearts® initiative. Program expansion into other
high-prevalence areas of the state was facilitated
through CDC and ASTHO grant funding.
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
A coordinated care team and healthcare providers in each
- Applied ABCS of Heart Health to achieve maximum
- Provided free blood pressure checks
- Tracked patients' blood pressure readings
- Worked with pharmacists to help patients adhere to
- Collaborated with Cooperative Extension Service
offices for referrals to their nutrition education
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
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
Joyce Lopez, Program Manager for Prevention
Oklahoma State Department of Health, Chronic Disease Prevention Service
Networking and collaboration
Wellness, health promotion, and disease prevention
October 31, 2016
Date updated or reviewed
November 18, 2022
Suggested citation: Rural Health Information Hub,
Heartland OK [online]. Rural Health Information Hub. Available at:
[Accessed 1 December 2023]
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.