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Addressing Heart Disease on a Large Scale

Kaiser Permanente PHASE grants help the organization and its community partners make heart disease treatment more accessible and affordable throughout Northern California. Pictured above, Dr. Laura Miller of the Community Health Center Network with a patient.

For Laura Miller, MD, a grant from Kaiser Permanente’s PHASE program means more outreach to low-income patients who desperately need help managing hypertension, diabetes, and cardiovascular disease.

Dr. Miller is the chief medical officer at Community Health Center Network (CHCN) in San Leandro, a nonprofit that supports 8 federally qualified health centers in the East Bay.

Kaiser Permanente is awarding nearly $6 million in grants over 3 years to CHCN and 17 other community organizations across Northern California to expand the reach and scope of Kaiser Permanente’s Preventing Heart Attacks and Strokes Every day (PHASE) program.

“We calculated that PHASE will reach 41,500 people with hypertension, diabetes, and cardiovascular disease,” Dr. Miller said of the ongoing impact to CHCN alone.

A Systematic Approach

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.

The heart healthy regimen has helped Kaiser Permanente reduce heart attacks and stroke-related hospital admissions among its own members by 60 percent since it began the program in 2002.

“Before the implementation of 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 are providing care to more than 115,000 patients with diabetes and hypertension.

Consistent Heart Health Care for Many

CHCN has partnered with Kaiser Permanente on PHASE since 2009. Previous grant rounds helped establish panel management programs within the clinics. In 2015, the PHASE grant helped with data analytics, “lifting the data reporting burden from the clinicians so they could focus on patient care,” Dr. Miller said. The next year, she said they focused on further identifying hypertension patients and implementing site-level clinical innovations.

Now, with the 3-year, $500,000 grant for CHCN, Dr. Miller said it is all coming together as they increase the number of participating care teams and focus on metrics for hypertension control, as well as provide information on medication adherence.

“To see comprehensive data, the patient’s medication adherence, and then look at that with the patient there in the room is just nirvana for us,” Dr. Miller said.

Golden Valley Health Centers  in the Central Valley’s Merced and Stanislaus counties serves over 110,000 individual patients with over 400,000 visits annually. That’s “the vast majority of the underserved population in the 2 counties,” according to Allyse Gilles, GVHC project manager.

Like CHCN, Golden Valley used its first grant to focus on data capacity. Now with its $150,000 grant, it will finalize rollout of the hypertension protocol and install a diabetes protocol, expanding from its 4 pilot sites to all 30 medical facilities.

“PHASE gives us access to the evidence-based work already done, thus removing the additional testing we might need to do in order to create an evidence-based model of our own,” Gilles said. “We can then focus on the real work: getting ahead of the game to prevent and control chronic diseases with our patients.”

Learn more about PHASE and all of the the 2017  PHASE grantees. 



diabetesheart diseasehypertensionPHASE

This Post Has One Comment

  1. Thank goodness for wonderful people like Laura Miller who help make sure that low-income people in our community have access to the health care they need. Thank goodness also for the funding that Kaiser Permanente provides to safety net organizations like CCHN to make that care more widely available. Makes me proud to work here!

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