Preventing Heart Attacks and Strokes Everyday (PHASE)

What We Do

PHASE is a population health management program to care for people with/at risk of cardiovascular disease using Kaiser Permanente’s evidence-based clinical protocol that, when followed, reduces cardiovascular disease. PHASE combines medications and lifestyle changes to provide a cost-effective treatment for people with existing heart disease and those at a risk for developing it. Successfully implementing the program requires coordination among care providers and reliable patient data management.

Lifestyle changes are measured in the following ways: BMI Screening & Follow-up, Depression Screening & Follow-up, and Tobacco Screening & Follow-up. Health centers provide follow-ups to assist patients make recommended healthy changes.

Guidelines and Protocols

• PHASE Algorithm
• Standardized Procedure for Blood Pressure Management
• Standardized Procedure for Management of Type 2 Diabetes
• Use of Aspirin for Management of Patients at High Risk for Cardiovascular Events
• Use of Angiotensin-converting-enzyme Inhibitors and Angiotensin Receptor Antagonists for Management of Patients at High Risk for Cardiovascular Events
• Use of Statins for Management of Patients at High Risk for Cardiovascular Events

Promising Practices

To access promising practices related to PHASE, such as hypertension, diabetes, and lifestyle screenings, click here.

Trainings

Aliados Health Training Calendar

Interventions

As part of this grant, participating health centers are implementing the following interventions:

• Shared clinical guidelines agreed to by Aliados Health Medical Directors/CMOs
• Regular meetings with PHASE Champions and discussion of initiatives in peer network meetings
• Aliados Health participation in Kaiser Permanente Learning Community and Convenings to share resources, new strategies and updates with health centers
• Aliados Health templates for RN standardized procedures and case conference webinars
• Standardized CDS tools for PHASE
• Health center staff participate in trainings offered by Kaiser Permanente and Support Team at no cost to them (e.g. motivational interviewing, panel management, health coaching, and more)
• Aliados Health develops regular PHASE reports for use by eCW health centers and provides training on the use and interpretation of reports
• Aliados Health and community health centers collect data and assess performance quarterly

Who We Serve

Patients ages 18 and over with one or more of the following diagnoses are eligible for the program:

• Clinical Atherosclerotic Cardiovascular Disease (ASCVD)
  • Abdominal Aortic Aneurysm (AAA), Peripheral Artery Disease (PAD), Cerebral Vascular Accident (CVA) /Transient Ischemic Attack (TIA), Coronary Artery Disease (CAD)
• Diabetes (DM)

Funder

This project is funded by The Kaiser Foundation Hospital Fund for Community Benefit Programs at the East Bay Community Foundation.

Project Timeline

January 1, 2020 – March 31st, 2021

Measures

The project team will use our four-point Evidence Based Care framework to focus on the following measures:

Process Measures	Outcome Measures
# of PHASE eligible patients identified	% of patients with hypertension with BP controlled
# of patients with diagnosis of diabetes	% of patients with diabetes with BP controlled
# of patients with a diagnosis of ASCVD	% of patients with diabetes with HbA1c > 9
# of patients with a diagnosis of hypertension	% patients with BMI, depression, and tobacco screening and follow-up
# of trainings completed	% of patients prescribed a statin
	%  uninsured patients with diabetes