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Heartland OK uses a quality improvement process to identify, control and increase the number of individuals being appropriately diagnosed, and treated for hypertension. Their overall goal is to reduces the number of heart attacks in the United States. LeFlore County is one of the nine counties that have been selected for this initiative.

Patient Criteria:

* Must be between the ages of 18-85 years.

* Newly diagnosed and placed on diuretic and/or antihypertensive medications OR

* Previously diagnosed, on/or prescribed medication, but not controlled OR

* Presence of social determinants that would lead to non-adherence with recommended care

* Exclusion factors: Acute or uncontrolled mental health or substance abuse issues.

PCP Determines Care Plan

* Blood pressure control target

* Current medication regimen and next steps

* Makes referrals to Care Coordinator at the Health Department

* Makes referrals for community based services as a result of care coordination.

Care Coordinator (RN)

* Evaluates patient as indicated by the primary care provider

* Blood pressure measurements

* Weight and calculates BMI

* Adherence to medication side effects

* Assessment for lifestyle change education

* Ensures patient is knowledgeable

* Documents visit and communicates with PCP


Coordination of Care

According to the CDC, one in three American adults has high blood pressure and is at risk for a heart attack, stroke, or heart failure. With coordination of care between medical providers and LeFlore County Health Department, this program would enhance the reduction in heart disease related morbidity and mortality by monitoring the blood pressure of patients during initiation of treatment or continued treatment of uncontrolled chronic high blood pressure, facilitate adherence to medication recommendations and connect patients to lifestyle management and preventive care services located within the community.


For more information contact Mandi Collins at

LeFlore County Health Department

1204 Dewey Avenue

Poteau, Ok 74953

Office: 918-647-8601

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