Million Hearts Tools for Change Resources

Community-Clinical Linkages

Community Team-Based Care**

If you are looking for examples of team-based care in a clinical setting, see Standardizing Clinical Practice.

**NOTE: Community team-based care (TBC) may involve community pharmacists, community health workers, public health nurses, patient navigators, and other community-based health care professionals.

ASTHO Million Hearts Webinar: Implementing Team-Based Care
The American College of Preventive Medicine (ACPM) and ASTHO co-hosted a webinar discussing the implementation of team-based care from the perspective of a public health agency, and the perspective of health systems and providers. The webinar recording includes presentations from ACPM, ASTHO, The Iowa Department of Public Health, the University of Iowa College of Pharmacy, and the Stanford Prevention Research Center.

Current and Potential Roles for Public Health Nurses in Hypertension Prevention and Control
This issue brief by the Association of Public Health Nurses provides evidence of the effectiveness of public health nurses in the prevention and control of hypertension, their role in care coordination, developing protocols and making referrals, provider and patient education, as well as possibilities for advancing the role of public health nurses.

Million Hearts Stories
The Association of Public Health Nurses provides the following stories illustrate the role of the public health nurse in hypertension prevention and control during January- June 2014 of the first cohort of ASTHO Million Hearts Learning Collaborative states.

The Hypertension Team: The Role of the Pharmacist, Nurse, and Teamwork in Hypertension Therapy
CDC's article reviews results from controlled clinical trials, studies involving contemporary technology, and cost-effectiveness analyses to propose a new model focused on improving blood pressure control through team-based care.

Community Guide's Recommendation for Team-Based Care to Improve Blood Pressure Control
The Community Preventive Services Task Force recommends team-based care to improve blood pressure control on the basis of strong evidence of effectiveness in improving the proportion of patients with controlled blood pressure.

Including Community Health Workers into the Public Health and Health Care Systems [recording]
On this peer group call for the ASTHO Million Hearts State Learning Collaborative, speakers from Trust for America's Health, the National Association of Medicaid Directors, and Minnesota Department of Health discussed payment structures for incorporating community health workers into public health and health care systems (view the slide deck).

Reducing Cardiovascular Disease Risk Using Patient Navigators, Denver, Colorado, 2007-2009
This article from November 2011 in the journal Preventing Chronic Disease highlights patient navigators and their successes in reducing risk of CVD among at-risk patients in a low-income population.

Partnering with Pharmacists in the Prevention and Control of Chronic Diseases: A Program Guide for Public Health
CDC's guide focuses on how public health can work with pharmacists to support use of Medication Therapy Management in chronic disease management initiatives.

National Forum Learning Session: Working with Pharmacists to Increase Medication Therapy Management
The National Forum and ASTHO have recorded a series of short conversations with clinicians to discuss how to implement policies, practices and system strategies that improve control of high blood pressure in patients. This session features a presentation from Brian Isetts from the University Of Minnesota College Of Pharmacy about the pharmacist's role in team-based care models.

Team Up. Pressure Down.
A nationwide program to lower blood pressure and prevent hypertension through patient-pharmacist engagement.

Community Team-Based Care for Hypertension Management Implementation Protocol (Arkansas)
This document outlines the implementation protocol for a community team-based care model being tested by an Arkansas Department of Health Local Health Unit and a private community physician to provide community team-based care for patients with uncontrolled hypertension.

Clinician Referral and Order Form to Nurse Care Coordinators (Arkansas)
This referral form was developed by the Community Team-Based Care Program for Chronic Disease Management for use by physicians for recommending patients in need of care to Arkansas Department of Health Nurse Care Coordinators.

ASTHO Case Study: Iowa's Million Hearts Initiative 
Iowa's Million Hearts Initiative is led by the Iowa Department of Public Health (IDPH) and leverages partnerships across sectors to support components of Million Hearts, particularly improving quality of care around the ABCS of heart health through team based care, education, and incorporating Million Hearts goals in to state-level strategic planning efforts. One component of this work involved supporting provider-pharmacist partnerships to improve community-based hypertension management.

Referral Process Workflow for Clinical Providers of Patients with Hypertension (Wicomico County, Maryland)
Detailing the referral process for various healthcare providers for patients with hypertension, this workflow identifies all of the stages of care expected to be completed for patients in the Million Hearts initiative. This workflow was developed by Maryland Department of Health and Mental Hygiene with partners Maintaining Active Citizens (MAC Inc.) and Peninsula Regional Medical Center.

ASTHO Case Study: Maryland P3 Program
Maryland's Patients, Pharmacists Partnerships (P3) is a partnership between the Maryland Department of Health and Mental Hygiene and the University of Maryland School of Pharmacy to improve hypertension and diabetes prevention and control by partnering with community pharmacists to provide medication therapy management services to employees of self-insured employers across the mid-Atlantic region, including Maryland.

University of Maryland's Center for Innovative Pharmacy Solution's "Knowledge Enterprise"
Co-sponsored by the Maryland Department of Health and Mental Hygiene, this is an online training center that offer online modules on Maryland's P3 Program, and the pharmacists' role in supporting Million Hearts.

Medical Reserve Corps Million Hearts Guide (Virginia)
This guide was developed by the Richmond City Health District to be given to medical reserve corps (MRC) volunteers for the Million Hearts initiative. It provided a guide for MRCs when calling patients and ensuring appropriate referral to primary care providers and working with patients on action plans.

Pharmacist Protocol (Virginia)
This was produced by the Virginia Department of Health for pharmacists. It provides action steps for following up with the patient.

Pharmacist Referral and Tracking Form (Virginia)
The referral and tracking form was developed by staff at the Virginia Department of Health for pharmacists. Its main purpose is to provide a tracking section for monitoring patients’ blood pressure.

Community Health Worker Referral and Tracking Form (Virginia)
This referral and tracking form was produced by staff at the Virginia Department of Health for community health workers or Medical Reserve Corps members. It provides a tracking tool for patient encounters to discuss lifestyle changes and any barriers.


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