Written by: Center for Care Innovations

Hypertension is a tough disease to manage. Patients can feel fine, even when their blood pressure is sky-high. At a gathering of 18 organizations working to lower hypertension across Northern California through Kaiser Permanente’s Preventing Heart Attacks and Strokes Everyday (PHASE) Program, Dr. Bo Greaves shared why it takes all of us — inside the clinic and beyond — to help patients manage this dangerous chronic condition.

In this video, you’ll hear the heartbreaking story of one of Dr. Greaves’ patients, Mona, who suffered a stroke at only 51.

A Community Coalition

Dr. Greaves tells us about Hearts of Sonoma County and its innovative approach to save other patients from what happened to Mona.

Hearts of Sonoma County came together around a simple goal: to reduce heart attacks and strokes in Sonoma County. With the support of Kaiser Permanente’s PHASE program, community health centers in the county adopted a common treatment guideline, and began pooling data. This way they could track progress across sites and learn from one another.

The hypertension numbers got better, but Hearts of Sonoma County wondered about the people in their community they were not seeing at the clinics. To better connect with the community where patients live their lives, the group started going beyond the clinic walls with a public outreach campaign. Promotores were trained and spread the word about the dangers of hypertension. New lines of communications were established so that these promotores could refer patients directly to the clinics.

Hearts of Sonoma County continues to expand their work today, with aims to become an Accountable Community of Health. This offers increased potential for this work to become more widespread in the community.

Lessons Learned

Dr. Greaves shares his “aha” moment: a care team includes the whole community. The more that health care organizations can build connections with the social organizations that make up the fabric of our patients’ lives — the family, apartment complex, neighborhood, faith community — the more likely we are to move the needle on hypertension, he says. And the more likely we are to save other patients from what happened to Mona.



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