A Community-wide Collaboration to Reduce Cardiovascular Disease Risk

The Hearts of Sonoma County Initiative

Allen Cheadle, PhD; Michelle Rosaschi, MPH; Dolores Burden, MSN, RN; Monica Ferguson, MD, MSHP; Bo Greaves, MD; Lori Houston; Jennifer McClendon, MPH; Jerome Minkoff, MD; Maggie Jones, MPH; Pam Schwartz, MPH; Jean Nudelman, MPH; Mary Maddux-Gonzalez, MD, MPH


Prev Chronic Dis. 2019;16(7):e89 

In This Article

Abstract and Introduction


Purpose and Objectives: Collaboration across multiple sectors is needed to bring about health system transformation, but creating effective and sustainable collaboratives is challenging. We describe outcomes and lessons learned from the Hearts of Sonoma County (HSC) initiative, a successful multi-sector collaborative effort to reduce cardiovascular disease (CVD) risk in Sonoma County, California.

Intervention Approach: HSC works in both clinical systems and communities to reduce CVD risk. The initiative grew out of a longer-term county-wide collaborative effort known as Health Action. The clinical component involves activating primary care providers around management of CVD risk factors; community activities include community health workers conducting blood pressure screenings and a local heart disease prevention campaign.

Evaluation Methods: The impact of the clinical improvement efforts was tracked using blood pressure data from the 4 health systems participating in HSC. Descriptive information on the community-engagement efforts was obtained from program records. Lessons learned in developing and maintaining the collaborative were gathered through document review and interviews with key informants.

Results: Favorable trends were seen in blood pressure control among patients with hypertension in the participating health systems: patients with controlled blood pressure increased from 58% in 2014 to 67% in 2016 (P < .001). Between 2017 and 2019, the community engagement effort conducted 99 outreach events, reaching 1,751 individuals, and conducted 1,729 blood pressure screenings, with 441 individuals referred to clinical providers for follow-up care. HSC scored highly on 6 essential elements of an effective coalition and achieved a degree of sustainability that has eluded many other collaboratives.

Implications for Public Health: Factors contributing to the success of HSC include 1) starting small and focused to build trust among participants and demonstrate value, 2) working within the framework of a larger effort, and 3) providing long-term, open-ended backbone support.


Improving the health of a population requires a multi-faceted approach that includes both community and clinical strategies.[1] Implementing these clinic/community strategies successfully often requires multi-sectoral collaborations that bring together a broader range of organizations and institutions than are part of typical public health coalitions.[2] For example, multi-sector Accountable Communities of Health have been part of many State Innovation Model[3] health improvement projects that are attempting to bring together a range of partners to work on health system transformation.[4]

Although effective collaboration is needed to bring about health system transformation, doing it well has proved challenging. In a recent study by Siegel et al[5] of 145 health system improvement collaboratives that had a reputation for being mature and effective, as few as 10 were judged to be mature enough to make true progress toward supporting a transformed health system. Some of the challenges that have limited the effectiveness of previous public health–oriented coalitions[6] are accentuated in these newer, larger collaboratives encompassing more sectors (ie, reaching agreement on goals, approaches, and steps to action among varied organizations with competing organizational objectives).

One way of overcoming these challenges is to learn from successful collaborative efforts. Substantial literature on what makes a successful coalition exists,[2,7,8] but we are aware of few published examples in which multi-sector collaborative efforts have been sustained over an extended period, and long-term sustainability is critical for creating a transformed, integrated health care system.

In this article, we describe the Hearts of Sonoma County (HSC) initiative, a county-wide, multi-sector collaborative effort to reduce cardiovascular disease (CVD) risk in Sonoma County, a medium-sized county in northern California. HSC grew out of Health Action, a larger multi-sector effort that has existed for more than 10 years. HSC is being evaluated using 1) a process evaluation to capture milestones in initiative development and factors associated with success, and 2) an outcome evaluation documenting changes in CVD outcomes (eg, blood pressure control) using pooled county-level provider data. This article describes the initiative and outcomes to date and identifies lessons learned and recommendations that may be useful for other, similar initiatives.