OAKLAND, Calif. — Kaiser Permanente Northern California is providing nearly $6 million in grants to reduce heart attacks and strokes among individuals and populations in local communities who are most at risk. The grants support 18 community organizations across northern California that will work together to expand the reach and scope of Kaiser Permanente Northern California’s award-winning Preventing Heart Attacks and Strokes Every day (PHASE) program.
Kaiser Permanente Northern California is also providing significant resources — including clinical expertise, training and technical assistance — and partnering with the Center for Care Innovations and the Center for Community Health and Evaluation to support the implementation of the program in community settings.
PHASE combines medications and lifestyle changes to provide an evidence-based, cost-effective treatment for people with existing heart disease and those at greatest risk for developing it, including individuals with diabetes who are ages 55 years and older. By applying evidence-based treatment to populations at risk, the PHASE program has successfully reduced heart disease morbidity by 60 percent among Kaiser Permanente Northern California members since 2002.
Between 1999 and 2014, heart attack rates among Kaiser Permanente Northern California members declined 40 percent, and the most deadly type of heart attacks plunged 72 percent. In addition, the organization’s blood pressure control rate for hypertensive patients is nearly 88 percent, compared to the national average of 61 percent.
“Before PHASE, patients with heart disease often needed many office visits and phone calls before getting the appropriate treatment,” said Marc Jaffe, MD, an endocrinologist and internist at Kaiser Permanente South San Francisco. “With the PHASE program now in place, we are seeing tremendous results as Kaiser Permanente and its partners are making heart disease treatment more accessible, affordable, consistent and convenient in the communities we serve.”
In 2006 Kaiser Permanente began sharing the program with community health centers through a combination of grant funding, clinical expertise and physician mentors. Today, 112 clinic sites in northern California, which includes 25 public hospital/health department clinics (representing 4 public hospital systems) and 87 clinic sites from 32 health centers (representing 4 consortia) are providing care to more than 120,000 patients with diabetes and hypertension.
“We are sharing the best of what’s working for our members with the larger health care community,” noted Yvette Radford, vice president of External and Community Affairs for Kaiser Permanente Northern California. “It’s more than writing a check to support this work, we are leveraging assets including Kaiser Permanente’s intellectual capital and clinical expertise to support the total health of the communities we serve.”
The majority of the grants will continue support for safety net health care organizations already using PHASE, to help them increase the number of patients enrolled in the program and expand the program’s scope to treat other conditions, such as hypertension. Other grants will help health care safety net organizations adopt team-based care models and make technical improvements that are foundational for implementing chronic care programs such as PHASE, and support evaluation and training efforts.
PHASE grants are based on each organization’s implementation plans and will be paid over the next two years. Recipients include:
- Alameda Health System: $500,000 grant to continue expanding its PHASE work. It will refine its approach to team-based care, and expand teams to include clinical pharmacy services, nurse educators, registered dieticians, certified diabetes educators and health coach.
- Community Health Center Network: $500,000 grant to focus its efforts on increasing the number of participating care teams and improving its metrics for hypertension control. CHCN will train care teams, enabling them to meaningfully engage patients and improve the cardiovascular health of the community.
- Community Health Partnership of Santa Clara: $500,000 grant to work with PHASE members to increase their ability to access and use real-time data analytics and reporting. CHP will use intensive practice coaching, on-site technical assistance and an interactive training approach to advance its workflow redesign, patient engagement and data collection.
- Redwood Community Health Coalition: $500,000 grant to expand its evidence-based care framework that supports the use of shared clinical guidelines; provide clinical decision support through optimization of its electronic medical record and standardized reports, and advance quality improvement.
- San Francisco Community Clinic Consortia: $500,000 grant to improve clinic use of the data analytics tool and improve patient outcomes and reporting. SFCCC will expand PHASE by increasing the number of participating clinics from three to five, and expand the PHASE target populations.
- San Francisco General Hospital Foundation: $500,000 grant to increase the number of participating clinics; optimize electronic tools for data reporting and visualization, develop roles of nurses and pharmacists in chronic disease management; enhance self-management support to include counseling for smoking cessation.
- San Mateo Medical Center: $500,000 grant to focus its efforts in data analysis and application, team-based care and behavioral health integration, including increasing depressing screening and treatment. SMMC will expand PHASE to additional patients.
- Santa Clara valley Medical Center: $500,000 grant to expand its PHASE target population to include non-diabetic patients, improving care delivery and strengthening information systems. SCVMC will expand PHASE to additional patients.
- San Joaquin General Hospital: $500,000 grant to implement the PHASE protocol in its three primary care clinic sites. The grant will also support a focus on enhanced quality and process improvement, data-driven decision making, team-based care and improved capacity for population/panel management.
- Camarena Health: $150,000 grant to implement the PHASE protocol for the first time in its six clinics. Grant funds will provide Camarena with the necessary resources to adopt, test and refine population health strategies.
- CARES Community Health: $150,000 grant to optimize its multidisciplinary care team approaches to better engage patients, and to build a culture of data-driven decision making to improve health outcomes.
- Chapa-De Indian Health Program: $150,000 grant to implement the PHASE protocol in both of its clinic sites. Grant resources will allow the program to adopt, test and refine population health management strategies.
- Community Medical Centers: $150,000 grant to implement the PHASE protocol at one of its clinic sites. Funding will support redesigned workflows to assist clinical staff with data entry and system optimization, and will provide staff with daily reports to help them identify and engage PHASE patients early on.
- Elica Health Center: $150,000 grant to adopt and participate in the implementation of the Kaiser Permanente PHASE protocol at four of its sites. Elica will identify, screen and serve at-risk patients targeted by PHASE. Elica will leverage and institutionalize skills acquired through PHASE coaching, training and technical assistance.
- Golden Valley Health Centers: $150,000 grant to implement the PHASE protocol at four of its clinic sites. The grant will help improve the organization’s ability to use population health data to profile, risk stratify patients in order to more efficiently provide treatment and support the creation of a plan to spread development of the PHASE protocol to all GVHC sites.
- Livingston Community Health: $150,000 grant to implement PHASE in its four clinic sites for the first time over the next three years. Participation in PHASE will provide LCH with the necessary resources to adopt, test and refine population health management strategies, which may be applied to other conditions in the future.
- Sacramento Native American Health Center: $150,000 grant to implement the PHASE protocol for the first time. SNAHC will work to build its capacity to collect, report and improve performance on a set of clinical and lifestyle measures for the program.
- Valley Health Team: $150,000 grant to adopt and implement the PHASE protocol at three sites for the first time. Valley will advance efforts to become a Patient Centered Medical Home by helping improve clinical integration, care collaboration, patient access and data analytics.
About Kaiser Permanente
Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America’s leading health care providers and not-for-profit health plans. Founded in 1945, our mission is to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve more than 11.3 million members in 8 states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and teams of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health.