Evaluation Spotlights & Strategies

Every day, we see examples of different approaches used in the field by colleagues working at the state, local, and community levels. With Field Notes, we can share some of these efforts from across the nation.

Please let us know whether there are specific types of efforts or activities you would like to see highlighted. Keep in mind that to provide you with timely examples, levels of evidence may differ for the example strategies.

Clinical-Community Health Worker Initiative [PDF-246K]
The Mississippi Delta Health Collaborative, an initiative of the Mississippi State Department of Health, provides leadership and guidance in the Mississippi Delta to improve the cardiovascular health of the population through the promotion of the ABCS (Aspirin use when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation).
Colorado Heart Healthy Solutions Program [PDF-479K]
To address growing rates of high blood pressure, elevated cholesterol, and other risk factors related to cardiovascular diseases in Colorado, the program helps people navigate community health systems.
Colorado Heart Smart Navigation Program [PDF-227K]
Patient navigators work with patients and community organizations to help manage blood pressure and other related conditions.
Community Heart Health Actions for Latinos at Risk (CHARLAR) Program [PDF – 284 KB]
CHARLAR is a lifestyle program that focuses on modifying risk for CVD and diabetes. It was developed by the Colorado Prevention Center in conjunction with community partners.
DC Million Hearts Program [PDF-3.3M]
The program brought together public and private organizations to reduce heart disease deaths in the Washington, D.C., area.
Delta Alliance for Congregational Health [PDF-298K]
A coalition of more than 25 churches in the Mississippi Delta work to reduce the risk of heart disease and help congregation and community members access health care.
Eskenazi Health Hypertension Group Education Program (EHHGEP) [PDF – 279 KB]
EHHGEP is a lifestyle program run by the Indianapolis-based Eskenazi Health system and is conducted in five of the health system’s Federally Qualified Health Centers.
Geisinger Ambulatory Pharmacy Care Program [PDF – 570 KB]
This Medication Therapy Disease Management (MTDM) program has its pharmacists and other health care team members coordinate care for patients in Pennsylvania and southern New Jersey who live with chronic diseases. Through a collaborative practice agreement, health team members, including specialty pharmacists, provide comprehensive medication reviews and can help identify, modify, and resolve medication-related problems.
Georgia West End Medical Centers Patient-Centered Hypertension Management [PDF-325K]
To help control hypertension among patients, West End Medical Centers, Inc., implemented Patient-Centered Medical Home-supported activities.
Grady Heart Failure Program [PDF – 129 KB]
This program at a safety net hospital uses team-based care to reduce high rates of hospital readmissions for heart failure patients through education and services that improve access to care.
HealthPartners Pharmacy Program [PDF – 714 KB]
Clinical pharmacists help patients with hypertension address their blood pressure and other health concerns at 16 HealthPartners primary care clinics in Minnesota. This medication therapy management program uses the Pharmacists’ Patient Care Process to deliver comprehensive care.
Kaiser Permanente Colorado Hypertension Management Program [PDF-598K]
This hypertension management system uses electronic medical records (EMR) and team-based care to provide effective care to patients with high blood pressure and other conditions.
Jacksonville Urban Disparity Institute Diabetes Rapid Access Program [PDF-306K]
The Diabetes Rapid Access Program (D-RAP) aims to remove barriers to care and provide patients with the tools needed to successfully manage diabetes and hypertension.
Maryland Learning Collaborative [PDF-495K]
The Maryland Department of Health and Mental Hygiene’s Center for Chronic Disease Prevention and Control and the Maryland Learning Collaborative developed a public health and clinical care partnership to improve state-level chronic disease outcomes, support quality improvement within health care settings, and advance primary care across the state.
Medical University of South Carolina (MUSC) Telestroke Program [PDF – 206 KB]
This program provides remote consultations and treatment recommendations for patients with suspected strokes who present in rural and community hospitals. The network operates as a ‘‘hub-and-spoke’’ model where MUSC, with comprehensive stroke resources (hub site), provides stroke consultations to smaller, often rural hospitals lacking such resources.
Michigan Improving Performance in Practice [PDF-413K]
Improving Performance in Practice has connected more than 35 medical practices with experts who provide coaching on techniques for improving quality of care and reducing costs.
Michigan Medicine and Meijer Pharmacy Program [PDF – 604 KB]
Michigan Medicine is addressing hypertension by embedding ambulatory care pharmacists into all of their primary care clinics and several partnering retail pharmacy locations. Patients with hypertension are receiving coordinated care in this program, which is consistent with the Pharmacists’ Patient Care Process.
Mississippi Delta Cardiovascular Health Examination Survey [PDF-320K]
This survey describes health behaviors and heart disease risk factors. Before 2011, no local-level surveillance of cardiovascular disease trends was available in the Mississippi Delta Region.
North Dakota MediQHome of Blue Cross Blue Shield [PDF-320K]
MediQHome helps improve quality of care through collaborative decision making, coordination of patient care, and use of a clinical information management system.
Northwest Ohio Pathways HUB [PDF – 122 KB]
Based off a nationally recognized model to improve care coordination, this program partners with community health workers to connect people with or at risk of chronic disease to appropriate medical care and social services in the community.
Palmetto Primary Care Physicians Patient-Centered Medical Home [PDF-311K]
The patient-centered medical home model includes patient care coordinators who help ensure that high-risk individuals receive patient-focused care.
Pharmacy Cardiovascular Risk Reduction Project [PDF-459K]
This project aims to improve patient care and health outcomes in the Mississippi Delta region by using medication therapy management approaches.
Residency Program Collaborative and Community Health Center Collaborative in Pennsylvania [PDF-304K]
This statewide program aims to enhance patient care at medical residency program sites and community health centers by using the patient-centered medical home and chronic care models.
Rural Arizona Medication Therapy Management (RAzMTM) Program [PDF – 602 KB]
Funded by the Arizona Department of Health Services, RAzMTM assesses the effectiveness of telehealth pharmacy services that are aimed to improve the health of people who are medically underserved. The program uses cloud-based software to help pharmacies and health plans implement MTM services that help manage chronic diseases and reduce adverse drug events in patients.
San Francisco Health Network Hypertension Health Equity Project [PDF – 127 KB]
This program in primary care clinics uses data-driven quality improvement to improve blood pressure control for African Americans with high blood pressure in the San Francisco Health Network.
St. Johnsbury, Vermont Community Health Team [PDF-656K]
The St. Johnsbury Vermont Community Health Team (CHT) Model includes an integrated group of multidisciplinary practitioners, including community health workers (CHWs), that address the spectrum of medical and nonmedical needs of patients with chronic disease conditions.
University of California, San Diego (UCSD) Pharmacy Program [PDF – 782 KB]
The University of California, San Diego serves patients with hypertension through a pharmacist-physician collaborative practice in three family medicine clinics. Using the Pharmacists’ Patient Care Process, pharmacists collaborate with physicians and patients to treat hypertension.
University of Mississippi Medical Center (UMMC) Remote Patient Monitoring (RPM) Program [PDF – 195 KB]
The UMMC Center for Telehealth has been providing RPM services to patients with chronic conditions since 2013 to improve condition management. RPM allows patients to share biometric and self-report data in real time with their care teams through tablets and specialized devices.
University of Southern California (USC) School of Pharmacy California Rights Meds Collaborative (CRMC) [PDF – 193 KB]
The USC School of Pharmacy, in partnership with LA Care Health Plan, launched CRMC to address suboptimal medication therapy for patients with diabetes and hypertension. CRMC trains pharmacists to deliver Comprehensive Medication Management (CMM) in the neighborhoods where patients live and work.
Vida Sana Program [PDF – 281 KB]
The Vida Sana Program is implemented by the Clínica Esperanza/Hope Clinic (CEHC), a community-based clinic located in Providence, Rhode Island. CEHC provides high-quality, culturally sensitive medical care using volunteers to serve adults without health insurance.

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Paul Coverdell National Acute Stroke Program (PCNASP) State Profiles: Year 5

PCNASP aims to improve the quality of stroke care and stroke outcomes. These two-page profiles summarize PCNASP’s state recipients’ program activities and outcomes for program year 5 (June 30, 2019 to June 29, 2020).

State and Local Public Health Actions (1422) Program Profiles

To offer a snapshot of activities and progress, CDC created customized profiles of State and Local Public Health Actions to Prevent Obesity, Diabetes, and Heart Disease and Stroke (1422) program awardees. The program profiles describe each funded awardee’s use of the Dual Approach and mutually reinforcing strategies.

WISEWOMAN Briefs

WISEWOMAN briefs provide guidance and resources for managers of WISEWOMAN programs.

WISEWOMAN Innovation Recipients

Seven out of 30 WISEWOMAN recipients received additional Innovation funding. All Innovation recipients share the goal of improving outreach to women who are at an increased risk of cardiovascular disease (CVD).

Learn more about the WISEWOMAN Innovation recipients by reading an overview of their funding and their Innovation Spotlights:

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Indicator spotlights give funded programs a list of potential indicators to explore for planning and evaluation.

The implementation guides describe key lessons learned from evaluations of selected models.

Sodium Reduction in Communities Program Implementation Guide
This implementation guide can help assist food service staff and public health organizations reduce sodium in food service organizations by drawing upon the experiences gained during the Sodium Reduction in Communities Program (SRCP). The guide provides information on how to implement activities related to four SRCP strategies.
The Pharmacists’ Patient Care Process Approach: An Implementation Guide
This implementation guide is for public health practitioners and health care professionals to help engage pharmacists in hypertension management through the Pharmacists’ Patient Care Process. The Guide includes key examples from the Michigan Medicine Hypertension Pharmacists’ Program that health care teams can replicate in their own programs.
The Shands Jacksonville Patient-Centered Medical Home Diabetes and Hypertension Self-Management Education Model [PDF-1.9M]
The purpose of this implementation guide is to describe key lessons learned from the evaluation of the Diabetes and Hypertension Self-Management Education (DHSME) model implemented within the Shands Jacksonville Patient-Centered Medical Home (PCMH). This guide is intended for public health practitioners who are interested in implementing chronic disease self-management education models that reduce or remove barriers to healthcare while also strengthening community-clinical linkages.
The St. Johnsbury Community Health Team Model [PDF1.7M]
The purpose of this implementation guide is to describe key lessons learned from the evaluation of the St. Johnsbury Vermont Community Health Team (CHT) Model. This document is intended for public health practitioners who are interested in implementing a public health approach that is both a multidisciplinary coordinated team effort and promotes community-clinical linkages within their communities.
The Residency Program Collaborative and Community Health Center Collaborative [PDF-2.2M]
The purpose of this implementation guide is to describe key lessons learned from the evaluation of the Pennsylvania Academy of Family Physicians’ Residency Program Collaborative and Community Health Center Collaborative. This document is intended for public health practitioners who are interested in using a quality improvement learning collaborative model to better understand how to implement this approach within their communities.

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The Recipes for Public Health highlight strategies for state and local health departments to use in implementing chronic disease prevention by applying practice-based evidence from program evaluations.

Implementing a Statewide Learning Collaborative to Support Clinical Quality Improvement
Learn how to leverage partnerships between public health professionals and health care systems to improve patient care and reach more patients with cardiovascular disease based upon this Recipe for Public Health from the Maryland Learning Collaborative.
Build Powerful Public Health Partnerships
Learn how to develop powerful program partnerships with this Recipe for Public Health from the DC Million Hearts Program.

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