Cardiovascular Health Improvement Strategies

Policy, Community-wide

Overcoming system barriers to optimal cardiovascular health

Lead: HSD

  • Data-Informed Place-Based Upstream Strategies: Prioritizing interventions based on actual needs
  • Policy Change: Reimbursement for Preventive Services by Non-Licensed Providers
  • Prevention Focused Community Education
  • Improved Community CVD Health: Outcome-specific - measure and show that CVD rates are being improved
    • Coordinated Population Health Management
    • Capture & Reinvest for ROI & Sustainability

Goals & Accomplishments

  1. Support Health Action in piloting an accountable community for health

    Accomplishments

    • Participated in CACHI trainings and conferences throughout the year providing technical assistance and support around portfolio of interventions refinement and impact, data sharing, and ACH governance and sustainability
    • Participated in stakeholder planning process to redesign Health Action governance structure to support:
      • Greater community engagement and ownership
      • Investment in Health Action for systems change work and overall sustainability, including funding for Hearts of Sonoma County's work
  2. Participate in CalAIM process and implementation of outcomes

    Accomplishments

    • Initiated conversations with Partnership HealthPlan around partnering with community based organizations to provide case management services for high utilizer patients to meet CalAIM Medi-Cal reform requirements coming in 2022
    • Ceres helped draft language for home delivered/medically tailored meal benefit under proposed In Lieu of Service benefit structure included in CalAIM Medi-Cal reform
  3. Participate in educating community on tobacco/nicotine/vaping

    Accomplishments

    • Center for Well-Being provides youth education on the risks of vaping and flavored tobacco products through their school-based Project TRUE program. Youth presented posters on BH and vaping at a Virtual Town Hall and were invited to present to SCOE.
  4. Participate in shaping policies and encouraging systems change to support CV health

    Accomplishments

    • Hearts of Sonoma County developed and submitted letters to Sebastopol City Council and Sonoma County Board of Supervisors urging adoption of tobacco retail policies banning flavored tobacco and vaping products
    • Developed data story as communications tool to illustrate the complex social, economic, and health root causes driving cardiovascular disease in Sonoma County

Cardiovascular Health Improvement Strategies

Optimal clinical-community care for cardiovascular health

Lead: Clinical and Community Partners

  • Identify SDOH Needs (starting with Food Access)
  • Assessment and Mapping to Community Resources
  • Care Coordination, Work Flows and Staffing (CHWs, other)
  • Bi-directional/Closed Loop Referral Platform & Tracking
  • Prevention-Focused Efforts including Community to Clinical Referrals
  • Prevention-Focused Efforts including Community Based Strategies

Goals & Accomplishments

  1. Promote/establish shared planning around health and social care needs
    • Support CHI in leading efforts for shared/common resource and referral platform
      • Accomplished: Started dialogue with KP, St Joseph, Sutter, and RCHC about potential to migrate to shared platform or share data across platforms for shared planning and care coordination
    • Convene joint CHI-HSC meeting around infrastructure needs to support social needs screening and closed-loop referrals
    • Pilot closed-loop referral in at least 1 FQHC and 1 medical office
    • Pilot closed-loop referral in at least 1 CBO
  2. Expand and integrate CHWs into HSC clinical and social services organizations

    Accomplishments

    1. Center for Well-Being is conducting a pilot aimed at achieving hypertension control through CHW health coaching and resource navigation via the PRAPARE tool, in addition to virtual blood pressure monitoring using the Carium app.
    2. SCIHP worked with the Center for Well-Being to embed 2 FTE CHWs into their PHASE clinic (pilot paused during pandemic)
    3. SRCH is working with the Center for Well-Being to embed 2 FTE CHWs into their integrated clinical care team to provide health coaching and resource navigation via the PRAPARE tool

Individual, patient-level and Insitutional change

Optimal clinical care for cardiovascular health

Lead: Clinical Partners

  • Implement Best Practices and National Standards (examples: PHASE; high performing primary care)
  • Collaborative Learning

Goals & Accomplishments

  1. Collaborate with Kaiser Permanente and RCHC to promote and expand PHASE work
    • Host quarterly PHASE learnings at HSC meetings

      Accomplishments

      • January: SCHIP Integration of CHWs for PHASE patients
      • February: Alexander Valley Health -- Million Hearts Hypertension Control Champion
      • March: RCHC PHASE Deep Dive with Aggregated FQHC Data
      • April: Kaiser Presentation on Role of Pharmacists on Care Team
      • August: Kaiser Permanente PHASE in COVID-19 Adapted Environment
    • Support/facilitate PHASE participation at health system level

      Accomplishments

      • Conducted individual CHI-HSC joint representative meetings with key health system partners (Sutter, St Joseph, Kaiser Permanente, RCHC)
      • Sharing RCHC podcasts on PHASE and other clinical learning with Hearts of Sonoma County members and partners, including October interview with Kaiser
  2. Develop and implement pilot projects to support and promote clinical tobacco/nicotine screening and cessation
    • Pilot HSC tobacco/nicotine cessation priorities in at least 1 clinical partner organization

      Accomplishments

      • Number of community health centers screening for vaping increased from 4 to 7 out of 12 between May 2019 and October 2020
      • One additional health center added e-referrals for tobacco use/vaping

Foundational support for sustainability & success

Lead: HSC)

  • Shared Vision
  • Hearts of Sonoma Member Organization Leadership Support
  • Portfolio Financing (Funding)
  • Backbone Support
  • Outcomes Metrics & ROI
    • Data sharing agreements & planning
    • Research & Evaluation

Goals & Accomplishments

  1. Create 5-year vision for impact of HSC through Cardiovascular Portfolio of Interventions (POI)

    Accomplishments

    • Transitioned backbone support to CBO partner (Ceres Community Project) to lead and build capacity in strategic planning, collaboration, and sustainability
    • Begun this project. 2021 priorities:
      • Complete Fact Sheet on value of HTN control so we have data to project costs savings from various interventions/improvements in risk factors
      • Identify key metrics to track related to social needs screening/referral and to reduction of CVD risk factors/prevention efforts
  2. Identify data measures to evaluate progress and effectiveness of HSC plan to achieve vision.
    • Resolve issues/reach consensus on common clinical data metrics
      • Accomplishment: Agreed on expanded clinical data metrics and to reset 2019 as baseline year. Added statin prescribing and diabetes measures; will also request race, gender, and insurance status
    • Identify metrics related to social needs screening
    • Identify metrics related to CVD reduction of risk factors and improved health outcomes
    • Renew data sharing agreement in support of these measures
      • Accomplishment: Renewed data sharing agreement for five more years (through July 2025), with all community health centers in Sonoma County now included
  3. Secure commitment for two years of backbone funding/investment for HSC
    • Develop statement of return on investment (ROI) for improved BP control
      • Accomplishment: Began work with CACHI Value of Prevention Team to develop fact sheet projecting the financial and social return on investment of improving blood pressure control
    • Develop business case and sustainability proposal for Portfolio of Interventions
      • Accomplishment: Developed and tested "sustainability pitch" at Fall 2020 CACHI convening

The vision of Hearts of Sonoma County is to reduce heart attacks and strokes as a major killer of people in Sonoma County. Hearts of Sonoma County is improving cardiovascular disease prevention and management through active collaboration across healthcare organizations, community and social service partners, and community members to inspire good health and achieve health equity.

Contact Information

Reilly Briggs

Ceres Community Project