The Healthy Hearts project is part of the We Choose Health Initiative in Illinois.

We Choose Health is supported by a $25 million Community Transformation Grant (CTG) from the Centers for Disease Control and Prevention (CDC). The funding, $5 million per year over five years (2016), was awarded after a highly competitive national application process.

Created by the Affordable Care Act, the Community Transformation Grant (CTG) program supports states and communities that tackle the root causes of poor health so Americans can lead healthier, more productive lives. By promoting healthy lifestyles, especially among population groups experiencing the highest rates of chronic disease, these grants will help improve health, reduce health disparities, and control health care spending.

To improve health in communities, it is important that clinicians are aware of the health of the whole community to effectively treat the individual patient. This project will integrate the use of electronic medical records and population health data to get a full picture of the health in communities. The Department of Public Health is working with federally qualified health centers (FQHCs) to implement a quality improvement dashboard tool that enables clinicians and patients can work together to better treat and manage hypertension, cholesterol, smoking cessation, and other risk factors.

Healthy Hearts is using open source software developed by the Office of the National Coordinator for Health Information Technology (ONC): popHealth. This software is housed at the Public Health Node, and uses electronic health record information to create data dashboards. Dashboards will report each provider's use of best practice guidelines to identify and treat cardiovascular disease.

In addition, community level data will be used by local health departments to improve community services related to cardiovascular disease.

Key project goals are:

• Integrate public health and primary care in nonmetropolitan communities in Illinois
• Support clinics and health departments in the implementation of national guidelines for cardiovascular health
• Use a population approach to cardiac prevention and care to link services and increase the integration of public health and primary care (clinics, providers, LHDs, CBO's). Reduce individual and community factors contributing to chronic cardiac disease
• Improve provider use of data dashboards to identify provider and clinic opportunities for improvement
• Reduce health care costs through cost avoidance: improved monitoring and detection, improved self-management, and improving community services will reduce the need for acute care.
• Coalesce statewide cardiovascular (CV) content experts, thought leaders, associations, and activists to create a unified direction for improvements

Preventive Clinical Goals:

• 30% improvement in patients receiving care that meets national guidelines for
  • Aspirin use
  • Blood pressure monitoring
  • Hypertension treatment
  • Monitoring body mass index (obesity measurement and follow up)
  • Tobacco screening and cessation counseling
  • Cholesterol screening and maintenance / treatment
• Increased use of data dashboards for quality improvement processes in each clinic
• Enhance the use of clinical decision support to monitor high risk patients, support self-management, and link community services.
• Educational opportunities on clinical improvement strategies, including team-based care and chronic disease management classes

Community Goals:

• Increased number of public health and primary care partnerships focusing on cardiac, chronic and preventive care issues
• Increased collaboration between primary care, community agencies, and LHDs: engage a team of providers (pharmacists, nurses, community health workers, etc)
• Identify and affect community-level chronic disease risk and protective factors, including chronic disease self-management classes, community wide sodium reduction initiatives, collaboration with community partners to increase resources for chronic disease self-management outside of a clinic setting