A Community-Wide Collaboration to Reduce Cardiovascular Disease Risk: The Hearts of Sonoma County Initiative
IMPLEMENTATION EVALUATION — Volume 16 — July 11, 2019
Sonoma County’s Health Action Collaborative, formed in 2007, focused on activities to improve health systems, education, and economic well-being among residents. In 2014, Hearts of Sonoma County was established as part of the health system improvement efforts building on Kaiser Permanente’s PHASE program and including a focus on clinical quality improvement for cardiovascular disease in 4 Sonoma County health systems. In 2017, the community engagement workgroup was formed to deploy community health workers to conduct blood pressure screenings in the community, improve community and clinical linkages, and build and launch a communitywide media campaign called It’s Up to Us.
Sonoma County Health Action Collaborative, overall structure and health care activities, the Hearts of Sonoma County Initiative, Sonoma County, California. Abbreviations: CVD, cardiovascular disease; PHASE, Preventing Heart Attacks and Strokes Everyday.
Hearts of Sonoma County’s Logic Model outlines the evaluation plan and includes inputs, outputs, and outcomes. The inputs include partners, aligned collaboratives, and funding. The outputs include activities in the four areas of clinical services, community programs and services, clinical and community linkages, and policy/systems/environment. Sample measures are included for each activity. Outcomes include short-term, intermediate, and long-term indicators. Short-term indicators include increased public awareness of CVD risk factors and community resources to prevent, treat, and manage CVD as well as increased knowledge of how to prevent, treat, and manage CVD. Immediate outcomes include reduced prevalence of risk factors and CVD and improved control and management of risk factors and CVD. Long-term indicators include reduced cardiac events, reduced heart disease and stroke, and reduced CVD related costs.
Cardiovascular disease portfolio of interventions logic model, the Hearts of Sonoma County Initiative, Sonoma County, California. Abbreviations: CHW, community health worker; CVD, cardiovascular disease; ED, emergency department; PHASE, Preventing Heart Attacks and Strokes Everyday.
The Center for Community Health and Evaluation (CCHE)’s framework on essential elements needed for successful collaboration includes the following: shared purpose, essential people at the table, adequate structure and support, taking action, effective leadership, and active collaboration. “Community and equity” are at the center of the diagram with the essential elements in a circle around the center.
Essential elements needed for effective collaboration, the Hearts of Sonoma County Initiative, Sonoma County, California. Abbreviation: QI, quality improvement.
Figure 4 shows trends in blood pressure control for individuals aged 18 to 59 years; results were similar in other age groupings. The change was significant, increasing from 58% who had their blood pressure controlled in 2014 to 67% in 2016; HEDIS benchmark trends for a comparable measure essentially did not change during that same period.
Percentage of hypertension patients aged 18 to 59 years with controlled blood pressure, the Hearts of Sonoma County Initiative, Sonoma County, California.
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