Spotlight: Georgia Mountains Health
The Centers for Disease Control and Prevention (CDC) is thrilled to recognize Georgia Mountains Health as a Million Hearts® Health System.
Georgia Mountains Health is a non-profit primary care organization with a full time medical and dental staff providing care in several north Georgia counties. It is being recognized as a Million Hearts® Health System for its work to achieve greater than 80% on cholesterol management and smoking cessation performance measures, improve its blood pressure control rate, and provide people in rural north Georgia the health-related social services they need to achieve optimal cardiovascular health.
Strategies for Success
Using Data to Drive Improvement
Georgia Mountains Health monitors clinical quality measures, including measures related to blood pressure control, cholesterol management, and smoking cessation, and recognizes clinicians for high performance on these measures on a quarterly basis. Achieving greater than 80% on cholesterol management and nearly 100% on smoking cessation measures demonstrates Georgia Mountain Health’s commitment to preventing heart attacks and strokes.
Prioritizing Hypertension Control
With both a self-measured blood pressure monitoring (SMBP) device loaner program and a remote patient monitoring (RPM) program, Georgia Mountains Health aims to help patients improve blood pressure control.
Georgia Mountains Health is both encouraged and excited by the success of our Blood Pressure Remote Patient Monitoring Program, which has contributed to significant health improvements for our patients with hypertension. This program has empowered individuals with chronic conditions to actively engage in their treatment plans, thereby enhancing their quality of life.
Patients with blood pressure readings exceeding 140/90 mmHg are invited to access devices through a sliding scale payment model and can either keep the cuff for a low cost or elect to return the cuff when their blood pressure measurements have consistently remained within normal levels for two weeks. Blood pressure readings are sent directly from the loaner devices to patient portals through an app. Clinical staff check readings throughout the day and can communicate with patients as needed to make real-time adjustments to medications.
Caring for the Whole Patient
In addition to the focus on leveraging more regular blood pressure readings, Georgia Mountains Health introduced a Community Health Worker (CHW) program in March 2024 to provide essential support tailored to individual needs. Since the program’s inception, CHWs have engaged in over 370 patient interactions.
All patients undergo annual risk screenings using PRAPARE assessments; individuals with health-related social needs are referred to CHWs who facilitate connections to critical services such as food resources and transportation assistance. Additionally, CHWs play an integral role in enhancing health literacy and medication adherence and support patient use of RPM initiatives related to blood pressure monitoring and glucose management.
Congratulations!
Georgia Mountains Health’s commitment to wellness is evident and demonstrates the impact a health system can have on the cardiovascular health of its patients, staff, and community. We are pleased to honor Georgia Mountains Health through the Million Hearts® Hospitals & Health Systems Recognition Program for working systematically to improve the cardiovascular health of those it serves.
Learn more about the Million Hearts® Hospitals & Health Systems Recognition Program and the effective strategies that can be used to prevent cardiovascular events.