Why Heart Attacks and Strokes?

  • More than 800,000 people in the United States die from cardiovascular disease (CVD) every year*.
  • More than 1.5 million people in the United States suffer from heart attacks and strokes every year*.

With funding from Kaiser Permanente, Aliados Health is part of a national effort to help prevent heart attacks and strokes among people who are at greatest risk. Since developing PHASE in 2002, Kaiser Permanente has reduced the incidence of heart attacks and strokes among its members by more than 60%. Cardiovascular disease, including heart attacks and strokes, is the leading cause of death in our community.

*Statistic Source


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

Promising Practices

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


Aliados Health Training Calendar


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)


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


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


Health Center Participation

  • 2012-2014 grant cycle: four health centers participated
  • 2015-2016 grant cycle: four health centers participated
  • 2017-2019 grant cycle: eight health centers participated
  • 2020-2021 grant cycle: eleven health centers are participating

As of January 2020, Aliados Health PHASE health centers served approximately 22,300 patients diagnosed with hypertension. This is an increase in patients from approximately 15,951 in January 2017. These patients had a hypertension control rate of 67.8% as of March 31, 2017. By December 31, 2019, the rate of control had increased to 74.3%.

Aliados Health PHASE health centers saw an increase in diabetes control (A1c <9%) over the 2017-2019 grant period, from 66.2% in 2017 to 70.7% in 2019. Self-reported building block clinic assessments completed by Aliados Health PHASE health centers in 2019 showed improvement in all five building blocks from the 2017 assessment (overall score of 8.2) to the 2019 assessment (overall score of 9). The building block with the greatest improvement was “Data-Based Decision Making”, from 8.1 in 2017 to 9.6 in 2019. The 2019 assessment also included a new building block, “Patient-Team Partnership”, which scored 7.6 overall. These assessments help Aliados Health focus resources and trainings for health centers, and gauge how health centers improve over time.


Health Centers:

  • Alexander Valley Healthcare
  • Alliance Medical Center
  • Coastal Health Alliance
  • CommuniCare Health Centers
  • Marin City Health and Wellness Center
  • Marin Community Clinics
  • Petaluma Health Center
  • Ritter Center
  • Santa Rosa Community Health
  • Sonoma County Indian Health Project
  • West County Health Centers

Strategic Partners:

  • Kaiser Permanente Northern California Community Benefit Programs
  • The Kaiser Foundation Hospital Fund for Community Benefit Programs at the East Bay Community Foundation
  • UCSF’s Center for Excellence in Primary Care
  • Center for Care Innovations

Evaluation Assistance:

  • Center for Community Health and Evaluation


For more information, please contact Michelle Rosaschi.



    • Center for Care Innovations PHASE updates