SUCCESS STORIES
More Success Stories can be found on our Good and Healthy website.
Promoting Cardiovascular Health Through Team-Based Care
Sanford Health Brookings Clinic
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Mental Health is Health 1815 Year 4: Assessing Social Risk Factors at Sanford Health Brookings Clinic - Social, environmental, and behavioral risk factors faced by individuals are often closely tied to their
development of chronic disease and adverse health outcomes. To help their patients address these barriers,
Sanford Health Brookings Clinic began implementing a screening tool to assess for these risks in December
2019 as part of a South Dakota Department of Health Heart Disease and Stroke Prevention Program (HDSPP)
1815 Year Two funding opportunity. Over the past several years, Sanford has administered these screenings to
patients seen in the clinic for well visits or when something within their medical record indicated they could
benefit from a screening. As concerns are identified, patients are referred to the on-site social worker, who
assists with finding the appropriate resources to help address their need(s). READ MORE -
A Little Support Goes a Long Way: Addressing Risk Factors at Sanford Clinic Brookings throughout 1815 Year 3 - The likelihood of developing chronic disease and adverse outcomes can be greatly influenced by a variety of circumstances and situations. Sanford Clinic Brookings is working to combat barriers related to several social, environmental, and behavioral risk factors through the use of a screening tool implemented in December 2019. Screenings are given to patients seen in the clinic for well visits or when something within their medical record indicates they could benefit from a screening. When a need is identified through the screening, patients are referred to the on-site social worker, who can assist with finding the appropriate resources to help address the corresponding barrier. READ MORE
Huron Clinic
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Chronic Care Coordination and Self-Measured Blood Pressure Monitoring Programs Going Strong at Huron Clinic Throughout 1815 Year 4 - Throughout 1815 Year 4 (June 30, 2021-June 29, 2022), the Heart Disease and Stroke Prevention Program (HDSPP) partnered with Huron Clinic to partially fund a Chronic Care Coordinator. This individual provided management for high needs cardiovascular patients, each of which had multiple, additional co-morbidities. Another service the Chronic Care Coordinator provided was to complete Annual Wellness Visits for Huron's Medicare patients. During these sessions, the Chronic Care Coordinator assessed for any cognitive impairment and checked functional ability and safety levels. She also completed a depression screening, established an overall screening schedule for the next 5-10 years, identified any risk factors, and provided health education and preventative counseling and referrals.
In addition to their care coordination program, Huron continued utilization of their self-measured blood pressure (SMBP) monitoring program throughout this project period. SMBP allows patients with elevated blood pressure readings to take a blood pressure cuff home with them, monitoring their blood pressure readings regularly over a specified period of time (typically 2 weeks or more). Throughout that time, the patient communicates with their care team and makes adjustments to their treatment plan until their blood pressure is controlled (less than 140/90 mm Hg). This may mean adding or adjusting their medications, incorporating lifestyle modifications, or even making no changes at all if they find the patient's blood pressure levels are within normal range outside the clinic setting. READ MORE
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Huron Clinic Provides Chronic Care Coordination Through 1815 Year 2-3 - Huron Clinic has been partnering with the South Dakota Department of Health Heart Disease and Stroke Prevention Program (HDSPP) as part of the 1815 CDC cooperative agreement Implementing Interventions to Improve the Health of South Dakotans through Prevention and Management of Heart Disease, to better address increasing chronic disease rates amongst their population. As part of their efforts, Huron and HDSPP, worked together to implement a new chronic care coordination program in 2020. The Chronic Care Coordinator (CCC) oversees patients with high needs related to multiple chronic conditions, all of which have some form of cardiovascular disease, such as hypertension or high cholesterol, and/or diabetes. The CCC coordinates medical treatment, including 1) administering assessments, 2) developing care plans, 3) monitoring medication compliance, 4) establishing an ongoing relationship with patients, 5) serving as an advocate/champion for patient health, and 6) connecting patients with social and community support systems for continuation of care. All these services have been shown to prevent exasperation of chronic disease and poor health outcomes. READ MORE
Self-Measured Blood Pressure Monitoring
Platte Health Center Avera
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Platte Health Center Avera Implements Self-Measured Blood Pressure Monitoring Program Leading to Eye Opening Diagnoses for One Participant - Hypertension is a serious condition that can lead to life-changing consequences, but it can be managed. Knowing self-measured blood pressure (SMBP) monitoring is a great way to help patients manage their blood pressure, Platte Health Center Avera's clinics in Geddes, Platte, and White Lake decided to start a program.
One of the biggest challenges with the project was getting people to understand the seriousness of a hypertension diagnosis and all the effects it can have on the body. Some patients were reluctant to take home a blood pressure machine and track their numbers. So to address this challenge, Platte Health Center Avera made sure staff took time to talk through and educate the patients to help them see the value of monitoring their blood pressure and feel comfortable getting enrolled in the SMBP program.
Unfortunately, some patients agreed to be involved in the program but did not follow up or follow their treatment plan related to their hypertension diagnosis. However, of those who did participate, multiple people were surprised their blood pressures ran high at home, as they always assumed being in the provider's office was the reason for their high readings. READ MORE
Falls Community Health
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Promoting Self-Engagement and Blood Pressure Control in a Vulnerable Population at Falls Community Health: 1815 Year 4 - High blood pressure is one of the leading causes of cardiovascular disease. However, individuals are often unaware they have it and many people who have been diagnosed with hypertension do not regularly monitor their blood pressure. Self-measured blood pressure (SMBP) monitoring programs are an effective way to manage hypertension, decreasing risk for heart attack and stroke. The SMBP program at Falls Community Health (FCH) addresses blood pressure control and provides access to cuffs for ambulatory monitoring so patients who have barriers getting to the clinic can still be monitored remotely and address blood pressure control, improving their overall outcomes. READ MORE
Faulkton Area Medical Center
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Faulkton Area Medical Center Continues to Grow and Expand their Self-Measured Blood Pressure Monitoring Program throughout 1815 Year 4 - Improving hypertension control remains a priority at the Faulkton Area Medical Center (FAMC) through the continuation of the self-measured blood pressure (SMBP) monitoring program implemented as part of a partnership with the South Dakota Department of Health Heart Disease and Stroke Prevention Program. Since its roll out in March 2021, the clinic has been able to expand availability of their program to their hospital patients as well as their nutrition services department. Part of Faulkton's efforts included offering DASH (dietary approaches to stop hypertension) diet classes to patients enrolled in SMBP as well as non-participating community members, garnering a very positive response from class attendees. Participants in the SMBP program have relayed appreciation in the ability to monitor a part of their health at home and work with their medical provider to stay healthy. READ MORE
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Implementing a Self-Measured Blood Pressure (SMBP) Monitoring Program at Faulkton Area Medical Center - Heart Disease remains the leading cause of death worldwide. A concern even small, rural areas in South Dakota cannot escape. To combat high blood pressure within their community, a leading cause of cardiovascular related disease, Faulkton Area Medical Center implemented a self-measured blood pressure (SMBP) monitoring program in March 2021. Following the American Heart Association and American Medical Association's Target: BP program, Faulkton's team works with their providers to identify patients who would benefit from additional blood pressure monitoring. Participants are identified through information gathered during clinic visits and/or obtained from their medical records. Individuals meeting program criteria are sent home with a loaner blood pressure cuff or offered a time to bring their home machine to be checked for accuracy. Participants then monitor their blood pressure twice a day for two weeks and return for a follow-up appointment with their provider afterward. At that appointment, participants review the readings with their provider and determine their next steps. If their blood pressure remains elevated at home, participants continue monitoring twice a day while adjusting their medications and/or implementing lifestyle changes. If they are found to either not have hypertension or their hypertension is under control outside the clinic setting, known as white coat hypertension, they continue with their existing treatment plan and return the loaner cuff for use by the next participant. READ MORE
Community Pharmacy Enhanced Services Network of South Dakota (CPESN SD)
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1815 Year 4: CPESN SD's Continued Success through Pharmacy-Based Cardiovascular Risk Reduction Programing - It is well established that factors such as increased age, race, sex at birth, smoking, elevated lipids (cholesterol), high blood pressure, and diabetes can increase a patient's cardiovascular disease risk and risk of having a heart attack or stroke. To address some of these factors during the 1815 Year 4 project period (July 1, 2021-June 30, 2022) the Cardiovascular Risk Reduction Program (CVRRP) was designed. Overall goals of the program included lowering cardiovascular risk in South Dakota residents by addressing both elevated lipid levels and hypertension. READ MORE
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Year Two: The CPESN SD Hypertension Management Program Builds Upon Year One Success - In July 2019, the Community Pharmacy Enhanced Services Network of South Dakota (CPESN SD) began a partnership with the South Dakota Department of Health Heart Disease and Stroke Prevention Program (HDSPP). Through this partnership, community pharmacists across the state identified individuals with uncontrolled hypertension from their respective pharmacies. Participants were then enrolled in an 8-12 month intensive hypertension monitoring program (HMP) that included blood pressure goal counseling, lifestyle coaching, and training on how to properly obtain a blood pressure (BP) reading using a home BP monitor. READ MORE
Coteau des Prairies Health Care System
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Getting Back On Track With Blood Pressure Control at Coteau des Prairies: 1815 Year 4
Coteau des Prairies Health Care System has been partnering with the South Dakota Department of Health
Heart Disease and Stroke Prevention Program (HDSPP) since 2019 to address quality improvement needs,
expand use of team-based care and implement self-measured blood pressure monitoring. They understand
the importance of moving toward patient centered care and assisting with patient goal decision making as
evidenced by their continued focus on prevention and management programming through a team-based
approach. Patients appreciate the patient-centered care, one-on-one coaching, and adoption of the care
coordination model. Additionally, the improved outcomes and engagement for both patients and staff have
been positive results of this work. Providers have responded positively to feedback data and overall clinic goals
have improved. READ MORE -
Coteau des Prairies Grows Prevention & Management Programming During 1815 Year 3 - Coteau des Prairies (CDP) Health Care System has been partnering with the South Dakota Department of Health (SD DOH) Heart Disease and Stroke Prevention Program (HDSPP) team since 2019 to address quality improvement (QI) needs, particularly around their electronic medical record's (EMR) capabilities. Since the QI work is data-driven, the facility initiated a comprehensive dashboard for easy visualization and analysis of quality measures. Ongoing efforts ensure the dashboard is accessible and data is reviewed for thoroughness and accuracy. Additionally, a method of gathering provider assessment and feedback was established. The team works to streamline the process, available resources, and clinical support and coordination for maximum efficiency and patient benefit. CDP continues to implement SMBP with onboarding providers and clinical staff new to the program. READ MORE
Webster Clinic
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Self-Measured Blood Pressure Monitoring Program Implemented in Webster
Prevention is key in the fight against heart disease and stroke. By working to manage their hypertension,
patients learn to live a healthier lifestyle and take steps to continue that lifestyle for years to come. The Sanford
Webster Clinic helped facilitate one such step when they partnered with the South Dakota Department of
Health Heart Disease and Stroke Prevention Program (HDSPP) in December 2021 to implement a self-measured blood pressure (SMBP) monitoring program.
Program goals were established and after receiving the blood pressure monitors, staff were able to move
forward with enrolling patients. Initially, referrals were established during face-to-face visits with their provider.
Once enrolled, the patient was contacted every two weeks (unless the provider requested more frequent
contact) via phone to review their blood pressure readings. During their time in the program, patients received
a loaner blood pressure monitor which they continued utilizing as long as the provider felt the patient should be
in the program. Participation could range anywhere from a couple weeks to a month, or longer.
To simplify the enrollment process, each blood pressure (BP) monitor was placed in a small tote, along with premade packets for the patients containing all the necessary materials. These were placed in the outreach office at the clinic for easy to grab access and to make them easy to locate, the door was labeled as well.
Education packets included: information on how to take a blood pressure at home, education on controlling
high blood pressure, an additional blood pressure pamphlet reviewing complications of high blood pressure and
tips to lower blood pressure, a Better Choices, Better Health (chronic disease self-management program)
pamphlet, RN contact number, and a home blood pressure log for the patients to record their blood
pressure readings. READ MORE
Huron Clinic
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Huron Clinic Maintains Impressive Blood Pressure Control Rates Through 1815 Year 3 - Since February 2019, Huron Clinic has been working with the South Dakota Department of Health (SD DOH) Heart Disease and Stroke Prevention Program (HDSPP) to address increased prevalence of hypertension through a self-measured blood pressure (SMBP) monitoring program. SMBP participants are identified either by having an elevated blood pressure (>140/90 mm Hg) in the clinic or having elevated readings or a hypertension diagnosis noted within their medical record. Once participants enroll, they are sent home with a blood pressure cuff to check their readings twice a day for two weeks. After the two weeks, they work with their healthcare team to determine the next steps. If their blood pressure remains elevated at home, the participant will continue to check their blood pressure while implementing prescribed changes to their medication regimen or additional recommended lifestyle changes. This will continue until the participant reaches blood pressure control. If the readings are within the normal range, however, the participant is considered to have white coat hypertension (when an individual has an elevated blood pressure in the clinic setting but is otherwise within normal range). For these individuals, additional treatment is not necessary. Ruling out white coat hypertension before prescribing medication changes reduces the risk of over-prescribing to individuals not needing treatment, which could be dangerous and detrimental to their health. READ MORE
Madison Regional Health System
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Madison Regional Health System's Self Measured Blood Pressure Monioring Program Addresses a Common, Dangerous Health Issue that Can Lead to Life Altering Concerns - Most people recognize hypertension and are aware of why it should be a concern, however, it is a common diagnosis in many communities that can go easily unnoticed and untreated because of it's silent nature. Unfortunately, when untreated, hypertension can lead to chronic disease and ongoing health problems.
Using the American Heart Association (Target:BP) and American Medical Association model and materials as a guide, Madison Regional Health System (MRHS) decided to offer a self-measured blood pressure (SMBP) monitoring program to provide patients with additional tools and easy access to address their blood pressure needs. At MRHS, individuals who would benefit from participating in SMBP are recommended to the SMBP program. READ MORE
Community-Based Prevention and Response Programming
Kimball, SD
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Kimball, SD Achieves Cardiac Ready Community Designation - During a cardiac emergency, every second...every minute that passes without CPR (cardiopulmonary resuscitation) or use of an AED (automated external defibrillator) can mean the difference between life and death. In South Dakota (SD), it can take an ambulance 30 minutes to respond in the most remote areas of the state.
Kimball, SD is a rural community that lies on the I-90 Interstate between Chamberlain, SD and Mitchell, SD. Kimball does have Emergency Medical Services (EMS) but due to the volunteer make-up and rural nature, it has potential to take a while before an ambulance arrives during an emergency. The community knew they wanted to better prepare their citizens to help in an emergent cardiac event.
The Cardiac Ready Community (CRC) program helped educate and empower their community to be better prepared and more confident in helping someone experiencing a cardiac event until help arrives. Kimball residents worked together to create a safer, more knowledgeable, and better prepared community through the CRC program. Their CRC committee led the efforts to make this positive change a reality. READ MORE
Mitchell Rec Center
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Community-Based Self-Measured Blood Pressure Monitoring Program Using Physical Activity and Lifestyle Modification as the Intervention Piece - When the Mitchell Rec Center applied and received funding for self-measured blood pressure (SMBP) monitoring through the South Dakota Department of Health (SD DOH), they knew they were taking the road less traveled. Some of the goals of an SMBP program are to teach people the proper technique to take their own blood pressure (BP), collect frequent BP readings and ultimately have better blood pressure control. This type of program is traditionally operated in a clinical setting, but this did not stop them. The Mitchell Rec Center saw an opportunity to make a difference in their community and went for it. Participants in their program, Cardio Index, are loaned a blood pressure cuff for two weeks and are asked to check and record 10 blood pressure measurements. Then, the participants receive six weeks of personal training at no charge. After the six weeks, the participants take 10 more blood pressure readings. READ MORE