Skip to content

Heart Health
in the Community


clinics and hospitals
in the PHASE program


of hypertension patients
with blood pressure in control

In the Sierra foothills of Northern California, Chapa-De Indian Health operates 2 nonprofit community health centers that have seen a remarkable improvement in their ability to help American Indian and low-income patients with hypertension get their blood pressure under control.

With grant funding, training, and technical assistance from Kaiser Permanente’s PHASE program in partnership with the Center for Care Innovations, between January 2017 and December 2019 Chapa-De went from having 70% of its hypertension patients with blood pressure under control to 77%. High blood pressure is a major risk factor for heart disease and stroke. PHASE, stands for Preventing Heart Attacks and Strokes Every Day.

Chapa-De implemented a number of PHASE initiatives, including using medical assistants and Licensed Vocational Nurses to check patient blood pressure more often; launching a clinical-pharmacist led hypertension program that made it easier for patients to get needed labs and medication adjustments; and starting a blood pressure cuff loaner program to encourage patients to take their own blood pressure at home.

When we saw how PHASE benefited Kaiser Permanente members, we said, ‘Bring it on. We can do this for our patients.’ ”

“The majority of our patient population is underserved, and they’re disproportionately affected by hypertension and diabetes, which greatly increases their risk for heart attack and stroke,” said Meagan Mulligan, a family nurse practitioner who serves on Chapa-De’s PHASE team. “There’s a real sense of pride in our blood pressure control numbers and our ability to provide quality care for our patients.”

Improving Quality and Advancing Equity

The PHASE program combines medication 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. Heart disease and stroke are 2 of the nation’s leading causes of death, but because of PHASE, Kaiser Permanente members are significantly less likely to die of these conditions than other U.S. residents.

In 2006, Kaiser Permanente began sharing its life-saving PHASE program with community health centers, public hospitals, and community clinic consortia. By 2019, more than 200 Northern California clinic and hospital sites were participating in PHASE using the program to improve care for 174,000 patients.

Through in-person convenings, trainings, site visits, a PHASE playbook, and coaching — the PHASE program helped participating clinics and hospital sites to greatly improve blood pressure control in their patients.

Between January 2017 and December 2019 blood pressure control went from:

68% to 71%

in patients with hypertension

73% to 76%

in patients with diabetes

PHASE is also helping community health centers and public hospitals to advance their data reporting systems, culture of quality improvement, team-based care, and population health management systems — changes that will help them improve quality in other areas of patient care.

The PHASE program is just one example of Kaiser Permanente’s commitment to building partnerships with safety net clinics and institutions that serve on the front lines of health care for the uninsured and underserved. This work furthers our goal of ensuring access to care for those most in need and advancing health equity for all.

Back To Top