PHASE

Preventing Heart Attacks and Strokes Everyday (PHASE)

PHASE is a population health management program designed to reduce the risk of heart attacks and strokes in patients at high risk. PHASE follows Kaiser Permanente’s evidence-based protocol that has been shown to prevent one heart attack or stroke for every ten patients successfully enrolled in the program for five years. PHASE targets patients with diabetes mellitus, hypertension, and known vascular disease for a handful of interventions designed to control blood sugar, blood pressure, and weight, to prescribe cardio-protective medications, to assist in cessation of smoking, and to identify and manage patients at risk for depression.

Goal

By January 1, 2020, we will: (1) improve health outcomes, care coordination, and lifestyle indicators of PHASE patients. (2) expand the ability of care teams to make data-driven decisions; and (3) build the capacities to address health disparities by identifying and mitigating social determinants of health.

Population served

Adults 18 and over with a current or previous diagnosis of diabetes mellitus, hypertension, coronary artery disease (Heart Disease), TIA (transient ischemic attack) or Cerebrovascular Accident (Stroke).