Programs & Initiatives in Health Care – ASTHO Million Hearts

Programs & Initiatives in Health Care
ASTHO Million Hearts

Clinics and local public health making a difference in Minnesota’s hypertension control.

Million Hearts initiative

The Million Hearts® initiative focuses, coordinates, and enhances cardiovascular disease prevention activities across the public and private sectors in an unprecedented effort to prevent one million heart attacks and strokes by 2017.

Million Hearts LogoMillion Hearts® scales-up proven clinical and community strategies, bringing together existing efforts along with adding new programs to improve health across communities. In the end, helping Americans live longer, healthier, more productive lives.

The Million Hearts Initiative is a collaborative effort of the Centers for Disease Control and Prevention and Centers for Medicare and Medicaid Services. The Minnesota Department of Health is proud to be a Million Hearts partner.

The Minnesota project

The project goal is to enhance clinics’ ability to identify and manage patients with hypertension using a team based approach. To measure clinic performance, we support the implementation of the NQF-endorsed quality measure called NQF 18: Controlling High Blood Pressure. We support clinics and their staff in developing a process to pull the NQF 18 data and to identify patients with undiagnosed hypertension.

Project partners

  • Minnesota Department of Health
  • Healthy Northland
  • Duluth Family Medicine Clinic
  • P.S. Rudie Medical Clinic
  • Essentia Deer River Clinic
  • Riverwood Healthcare Center
  • Lake Superior Community Health Center
  • Sawtooth Mountain Clinic
  • Stratis Health

Project results – October 2013 to June 2015


  • Piloted the NQF 18 measure in six clinics. The clinics used their electronic health record (EHR) systems to identify adult patients with hypertension and to establish baseline and post-project NQF 18 measures.
    • Year 1 Clinics: There was a positive 6.5% change in blood pressure control after two years; Combined control rates were 68.5% for the baseline period; 75.0% for the final follow-up period.
    • Year 2 Clinics: There was a positive 2.9% change in blood pressure control.
    • An additional 1,011 patients have their blood pressure under control.
  • Five clinics pulled and reported data on patients with undiagnosed hypertension. Those sites identified an additional 1,961 patients with potentially undiagnosed hypertension.

Standardizing practice

  • The clinics developed processes to 1) pull NQF 18 data from the EHR and 2) identify patients with undiagnosed hypertension.
  • A total of 24 protocols were developed addressing accurate blood pressure measurement, treatment, home monitoring, follow-up, and referrals.
  • Two of the clinics with the same EHR vendor developed a process for documenting counseling for healthy lifestyle changes as retrievable, structural data.
  • The clinics adopted protocols for accurate blood pressure measurement technique and blood pressure treatment.

Clinical intervention

  • The clinics are developing and adopting evidence-based protocols for home blood pressure monitoring.
  • Some clinics are using clinical health coaches and others are using a care-team model, including care coordinators, to manage blood pressure.

Benefits of participating

Local Public Health (LPH)

  • Strengthens LPH – clinic relationship, which aligns with strategies being disseminated through national and federal health organizations and agencies


  • Clinics get access to public health expertise in their own community, helping them to meet the specific public health challenges in the communities they serve
  • Clinics share best practices, successes, and challenges with their peers

Get involved

Please contact Mary Jo Mehelich if you are interested in learning more about this work and how you can get involved.