taBLe o F content S
Letter from Governor Schweitzer and DPHHS Director Miles...................................2
Executive Summary ....................................................................................................4
Disease Burden Summary ...........................................................................................6
Goals, Objectives and Strategies
Program Evaluation ....................................................................................................21
A. Progress on Cardiovascular Disease Prevention and Control Plan 2000 ..........23
B. American Heart Association Warning Signs ...................................................24
C. Classification and Management of Blood Pressure for Adults ..........................25
D. ATP III Classification of LDL, Total, and HDL Cholesterol ..........................26
E. Key Stakeholders .............................................................................................27
F. Logic Model ....................................................................................................32
acK noWLeD geMent S
This state plan was prepared by the Montana Cardiovascular Health Program, Montana Department of Public
Health and Human Services, in collaboration with the Cardiovascular Disease/Obesity Prevention Task Force.
The expertise of the task force members and input provided by the state plan work groups and Native American
committee were invaluable in developing this state plan. We also would like to acknowledge Judy Garrity, who
helped transform the vision of the work groups into a working document.
e x ecutive Su MMary
The Montana Heart Disease • Enhancing the efforts of caLL to action
and Stroke State Plan for 2006- Indian Health Service and
The state plan objectives can
2010 outlines goals, objectives, tribal health departments to
only be accomplished with the
and specific strategies that can reduce cardiovascular disease
joint efforts of healthcare and
realistically be achieved within in Montana American Indians.
business leaders, insurers, public
a five-year period to improve • Creating systems within health agencies, policymakers,
the health of Montanans. The clinics and physicians’ offices and healthcare organizations
objectives and population-based to improve the management serving Montanans. Our state
strategies address prevention, of patients’ blood pressure, has already made inroads in
treatment and control of heart cholesterol levels and diabetes. decreasing the burden of heart
disease, stroke and major risk
• Enhancing policies in worksites disease and stroke by forming task
factors including high cholesterol
for blood pressure and forces and work groups to address
and high blood pressure.
cholesterol screening/referrals these urgent health issues. These
HigHLigHtS oF tHe and improving insurance partners are committed to making
State PLan coverage of medications for improvements in our residents’
heart disease, stroke, and health. The Cardiovascular Health
Key strategies in this five-year related risk factors. Program encourages you to join
plan include: this effort for a heart-healthy,
• Promoting tobacco cessation
• Increasing Montanans’ stroke-free Montana.
and tobacco-free work
awareness of heart attack and environments.
stroke signs and symptoms
and the need to call 911 so
that they receive timely care.
• Establishing systems within
hospitals to ensure patients
who have had a heart attack or
stroke receive care that follows
• Training Emergency Medical
Service (EMS) teams and
911 staff on use of a stroke
screening tool for rapid
identification and transport
of stroke patients.
4 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
i ntro Duction
Montana’S Heart DiSeaSe overarcHing goaLS FraMeWorK
anD StroKe State PLan
Montana has adopted the Healthy The Montana Heart Disease
As heart disease, stroke and People 2010 overarching goals to: and Stroke State Plan 2006-
related risk factors impact a 2010 emphasizes policies/systems
large portion of our residents, all • Increase quality and years of change and environmental
Montanans should be concerned healthy life. supports to impact heart disease
about preventing and managing • Eliminate health disparities. and stroke morbidity and
these health conditions. In mortality on a population-
Priority wide basis.
many cases, heart disease and
stroke can be prevented through
lifestyle behavior and controlling Certain populations have a high tHe PLan
risk factors such as high blood prevalence of heart disease and
pressure, high cholesterol, stroke risk, and addressing these The social domains of health
diabetes, and obesity. disparities is important in the care, community, and worksite
overall effort to control CVD in are presented in separate sections
The Montana Heart Disease
Montana. Based on the state’s of the plan. Each section was
and Stroke State Plan 2006-
burden of CVD, the following developed by a work group of key
2010 focuses on collaborative
priority populations have been stakeholders and contains a brief
activities with a variety of
identified: overview, measurable objectives,
partners to accomplish the stated
and strategies pertinent to that
goals and objectives. This plan • Adults over age 45 who are particular domain.
updates the 2000 cardiovascular at risk for heart attack and
disease (CVD) state plan that stroke due to cardiovascular In conjunction with development
was previously developed by the risk factors of the Montana Heart Disease
Montana Cardiovascular Health Risk factors include high and Stroke State Plan, the work
Program and the CVD/Obesity blood pressure, diabetes, groups also identified objectives
Prevention Task Force. It reflects elevated cholesterol, obesity, and strategies for a complementary
national priorities related to heart smoking, sedentary lifestyle, state plan focusing on obesity,
disease and stroke. previous cardiovascular event, nutrition, and physical activity.
or family history of CVD. The obesity state plan will be
PurPoSe oF tHe PLan
• Adults over age 65 implemented by the Montana
The purpose of the plan is to Older adults are more likely to Nutrition and Physical Activity
delineate activities that will experience a heart attack or Program and other partners. The
decrease morbidity and mortality stroke than young or middle- Montana Tobacco Use Prevention
associated with heart disease aged adults. Program has also developed a 5-
and stroke, reduce disease risk year plan. These three state plans
• American Indians will provide a comprehensive
factors among all Montanans, and
Montana American Indians approach to addressing heart
eliminate health disparities in the
are dying from CVD at an disease and stroke risk factors in
treatment of heart disease and
alarming rate. They also have Montana.
a higher prevalence of certain
risk factors including tobacco
use, diabetes, and obesity.
D i Sea Se BurD en SuMMa ry
In 2003, the Montana Montana is sparsely populated LeaDing cauSeS oF DeatH
Department of Public Health with a population density of in Montana anD tHe uS
and Human Services (DPHHS) only 6.2 persons per square mile.
produced a report describing the Over 60% of the population lives In Montana, approximately
burden of heart disease and stroke in one of eight “small urban” 30% of all deaths in 2003 were
and their associated risks.1 Using counties (ranging in population attributed to cardiovascular
data from the Montana Office from 16,673 to 129,352). A small disease. Heart disease and stroke
of Vital Statistics, the Behavioral urban county is defined as a non- were the first and fourth leading
Risk Factor Surveillance Survey metropolitan county with a city of causes of death, respectively.
(BRFSS), Youth Risk Behavior > 10,000 population or a county (Figure 1)
Survey (YRBS) and Medicare in a metropolitan area with less
hospitalization claims for than 1 million population. The
Montana residents, the burden remaining 48 counties in the
report presented data on the state are defined as “frontier,”
mortality from cardiovascular meaning a non-metropolitan
disease, heart disease, and stroke county without a city of 10,000 or
along with recent trends. more population.
This report also presented data
about the prevalence and trends
in selected modifiable Figure 1. Leading causes of death in Montana in 2003.
cardiovascular risk factors, along
with information about how Heart disease
well adults in Montana recognize 23.4%
the signs and symptoms of heart Other
attack and stroke. The data have 31.9%
been updated and condensed
to reflect current information
In 2003, Montana’s population
was 892,497 with a median age 3.1% Cancer
of 39 years. Over fifty percent Accident
were women, and approximately 6.1%
13% of Montana residents were Stroke Chronic lower
65 years or older.2 Ninety percent 6.8% respiratory disease
of Montana’s residents were white 7.0%
and the largest ethnic group,
American Indians, accounted for Source: Montana Ofﬁce of Vital Statistics, DPHHS, 2003
6.4% of the population.
1 The Burden of Cardiovascular Disease in the State of Montana 2003. View the entire report at
2 http://factfinder.census.gov (data accessed on 8/11/05).
6 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
Mortality from Heart Disease and Stroke
Cardiovascular Disease Mortality Trends in Montana
Between 1990 and 2003,
cardiovascular disease death rates While the vast majority of
declined for all Montanans and deaths due to heart disease and
the general US population. CVD stroke (87%) are in Montana’s
age-specific death rates increased white population, a considerable
sharply after age 55 for all disparity in these mortality rates
Montanans. Before age 45, CVD exists between American Indians
age-specific death rates were and whites in Montana. From
negligible for adult Montanans. 1991-1995 and 1996-2000,
heart disease and stroke mortality
Mortality from Heart declined significantly in whites but
Disease and Stroke not in American Indians. During
For the general US population and these time periods, premature
Montana, heart disease mortality deaths (i.e., deaths before age 65)
rates declined over the past decade. from heart disease and stroke were
However, the decline in Montana considerably higher in Indian men
was slightly slower than for the (45% and 36%, respectively) and
US. From the beginning of the Indian women (29% and 28%)
decade (1991-1995) to the end compared to white men (21% and
of the decade (1996-2000), the 11%) and white women (8% and
age adjusted heart disease 7%).3
mortality rate for American
Indians declined but remained Figure 2. Age-adjusted heart disease and stroke mortality rates for all Montanans, Montana
higher than either the general American Indians (AI) and the US, 1990-2003.
US population or Montana’s total 350
population. (Figure 2)
Of the 2,747 CVD deaths in 250
Montana in 2003, 571 deaths
(21%) were due to stroke. From 200
1990-2003, stroke death rates for 150
all Montanans and the general US
population declined at almost the
same rate. (Figure 2) Montana 50
American Indians experienced
higher stroke mortality rates 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
compared to either the general Heart disease - AI Stroke - AI
Heart disease - all MT Stroke - all MT
US population or Montana’s total Heart disease - US Stroke - US
population. Time period for AI mortality rates: 1991-1995 and 1996-2000.
Source: Montana Ofﬁce of Vital Statistics, DPHHS
National Center for Health Statistics
3Harwell TS, Oser CS, Okon NJ, Fogle CC, Helgerson SD, Gohdes D. Defining disparities in cardiovascular disease for American Indians: Trends in
heart disease and stroke mortality among American Indians and whites in Montana, 1991-2000. Circulation. 2005 October 11;112(15):2263-7.
From 1990-2003, the prevalence Figure 3. Trends in prevalence of diabetes and high blood pressure among all Montana and
of diabetes reported by adults American Indian adults, 1990-2003.
in Montana steadily increased. 40
(Figure 3) In 2003, Montana
American Indians reported
diabetes three times more
frequently than all Montanans.
Among Montana American
Indians, the diabetes prevalence
increased four percentage points 10
from 12% in 1999 to 16% in
2001 and 2003. 0
1990 1991 1992 1993 1994* 1995 1996 1997 1998 1999 2000 2001 2002 2003
Diabetes High blood pressure
High blood Pressure (HbP) Diabetes - AI High blood pressure - AI
Source: Montana BRFSS, DPHHS, 1990-2003.
From 1990 to 2001, the *Diabetes question changed in 1994 to exclude females with gestational diabetes.
Diabetes and high blood pressure question only asked in 1999, 2001 and 2003 for Montana AI.
prevalence of HBP among all Blood pressure questions not asked in 1996, 1998 and 2000 for all Montana.
Montanans steadily increased.
(Figure 3) However, after 2001
the prevalence of HBP declined
slightly to 21% in 2003 for all
Montanans. Over a five-year
time-period (1999 to 2003),
the prevalence of HBP among
Montana American Indians
increased eight percentage points
(from 26% to 34%).
8 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
High blood Cholesterol
The percent of Montana adults Figure 4. Trends in prevalence of high blood cholesterol and obesity* among all Montana and
reporting a history of high blood American Indian adults, 1990-2003.
cholesterol increased from 1990
to 2003. (Figure 4) In 1990,
25% of Montana adults reported
high blood cholesterol; in 2003
the prevalence increased to 30
30%. In 1999, 23% of Montana
American Indians reported high 20
blood cholesterol, and in 2003,
this prevalence increased seven 10
percentage points to 30%.
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
obesity High Cholesterol Obesity
High Cholesterol - AI Obesity - AI
In Montana, the prevalence of *BMI ≥ 30.0kg/m2
Source: Montana BRFSS, DPHHS, 1990-2003.
obesity among adults increased Cholesterol questions not asked in 1994, 1996, 1998 and 2000 for all Montana.
Cholesterol, height and weight questions asked only in 1999, 2001 and 2003 for Montana AI.
steadily from 1990 to 2001.
(Figure 4) Yet from 2001 to 2003,
the obesity prevalence remained
constant at 19%. From 1999 to
2003, the prevalence of obesity for
Montana American Indian adults
was double that of Montana, with
a prevalence ranging from 34%
Current Tobacco use
Adults in Montana reported
current use of tobacco at slightly
lower percentages than adults in
the US from 1990 to 2003.4 For
Montana American Indians during
1999 to 2003, the prevalence
of current smoking was almost
double that of all Montanans and
the general US population.
In 2003, 20% of all Montanans
and 36% of American Indians in
Montana reported current use
4 BRFSS Website www.cdc.gov/brfss
Heart attacK anD StroKe
Heart Attack Self-reported
In 2003, over 80% of respondents could Figure 5. Prevalence of heart attack signs/symptoms awareness among Montana adults,
correctly recognize the following heart 2003.
attack symptoms (Figure 5):
Chest pain or discomfort 95
• chest pain/discomfort – 95%
• pain or discomfort in arm or Arm or shoulder pain
shoulder – 89%
• shortness of breath – 84% Shortness of breath 84
Less than 65% of respondents correctly Weak, lightheaded 65
identified feeling weak, lightheaded or
Jaw, neck or back pain
faint. Fifty-three percent identified pain or discomfort 53
or discomfort in the jaw, neck, or back
*Trouble seeing in one
as heart attack symptoms. However, or both eyes
only 13% of adult Montanans knew all 0 25 50 75 100
symptoms of heart attack (including “no” *Correct response is no Percent
on the decoy symptom of trouble seeing Source: Montana BRFSS, DPHHS, 2003.
in one or both eyes).
The majority of respondents (85%)
were aware that they should call 911 if
someone is having a heart attack or stroke. Figure 6. Prevalence of stroke signs/symptoms awareness among Montana adults,
Respondents 65 years and older (78%)
were less likely to be aware of calling 911
if someone is having a heart attack or Numbness or weakness of
face, arm or leg
stroke compared to younger respondents,
18-44 years (86%), or those 45-64 years Confusion or trouble
of age (87%).
Trouble walking, dizziness
or loss of balance
Signs/Symptoms knowledge Trouble seeing in one
or both eyes
Over 85% of Montana respondents were Severe headache with no
likely to recognize the following as stroke
symptoms in 2003 (Figure 6): *Chest pain 31
• numbness or weakness of face, arm 0 25 50 75 100
or leg – 95% *Correct response is no Percent
Source: Montana BRFSS, DPHHS, 2003.
• confusion or trouble speaking – 87%
• trouble walking – 86%
Fewer respondents were aware that
dizziness or loss of balance and trouble
seeing in one or both eyes are symptoms
10 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
PrevaLence oF SeLF-rePorteD
Heart attacK anD StroKe
The percentage of Montana’s adult
Figure 7. Proportion of Montana adults who reported having a heart attack or stroke, by
population who reported ever having
sex, 1999 and 2003.
experienced a heart attack increased from
3.8% in 1999 to 5.1% in 2003. (Figure 7) 8
The overall lifetime prevalence of stroke 6.4
reported in Montana did not change 6
significantly from 1999 (2.2%) to 5.1 5.0
2003 (2.4%). (Figure 7) However, the
4 3.8 3.8
prevalence of stroke reported by women 3.1
increased compared to men, who showed 2.7
2.2 2.4 2.5
a slight decrease from 1999 to 2003. 2 1.7
DiScuSSion anD concLuSion
Overall Men Women Overall Men Women
Modifiable risk factors for CVD are
common in Montana, and the trends Heart Attack Stroke
show that the levels of obesity, diabetes, 1999 2003
high blood pressure and high blood
Source: Montana BRFSS, DPHHS, 1999 and 2003.
cholesterol increased steadily from
1990 to 2003. American Indian adults
in Montana continued to smoke and
to report having diabetes and high
blood pressure more frequently than all
Montanans over the decade.
In summary, the burden of CVD is
high in Montana, and the prevalence
of modifiable risk factors is increasing.
American Indians are at very high risk for
heart disease and stroke with particularly
high rates of diabetes, hypertension and
cigarette smoking contributing to the
risk. Premature cardiovascular mortality is
alarmingly high among American Indians.
The burden of CVD in the state indicates
the need for concentrated efforts on
prevention, treatment and control of heart
disease and stroke.
goaLS, oBjectiveS anD StrategieS
H e aLtHcare B. Decrease the percentage of adult American
Indians in Montana who report three or more
Many challenges exist to fully address heart disease risk factors for cardiovascular disease (smoking,
and stroke issues that affect all Montanans. These diabetes, high blood pressure, high cholesterol
barriers may include: levels, and obesity) from 18.2% in 2003 to
17.0% in 2009. [measured by American Indian
• Inadequate control of hypertension and high adapted-BRFSS]
C. Decrease the percentage of adult Montanans
• The cost of regular healthcare visits for those with metabolic syndrome as adapted from
residents lacking health insurance. the Behavioral Risk Factor Surveillance
• Insufficient insurance coverage for medications System (defined as 3 or more of the following
and services to manage heart disease, stroke and indicators: diabetes, high blood pressure, high
cardiovascular risk factors. cholesterol levels, and obesity) from 4.8% in
2003 to 4.0% in 2010. [measured by BRFSS]
• Geographical barriers in frontier counties that
may limit residents’ access, or rapid transport, D. Decrease the percentage of adult Montanans
to larger hospitals that can treat stroke and heart (aged 45 years and older) who report a history
attack. of cardiovascular disease (heart attack, angina
• Continuity of care once cardiac and stroke or stroke) from 11.7% in 2003 to 9.0% in
patients return home. 2010. [measured by BRFSS]
In spite of these challenges, progress is being made E. Decrease the percentage of adult American
to develop more comprehensive, coordinated Indians in Montana (aged 45 years and older)
systems in hospitals and EMS services throughout who report a history of cardiovascular disease
the state. The end result will be improved care of (heart attack, angina or stroke) from 18.9% in
cardiac and stroke patients. 2003 to 16.0% in 2009. [measured
by American Indian adapted-BRFSS]
HeaLtHcare goaL 1 StrategieS:
Decrease heart disease and stroke mortality • Encourage appropriate treatment of high blood
and morbidity among adults in Montana pressure and elevated cholesterol levels by:
- Ensuring that health care providers in clinics
and hospitals have access to a variety of
resources on the Joint National Committee
A. Decrease the percentage of adult Montanans VII5 guidelines that can be used for diagnosis
who report three or more risk factors for and treatment of high blood pressure.
cardiovascular disease (smoking, diabetes, high - Disseminating educational materials via
blood pressure, high cholesterol levels, and health care providers, pharmacies and
obesity) from 7% in 2003 to 6% in 2010. community organizations to encourage those
[measured by the Behavioral Risk Factor at risk to control their high blood pressure.
Surveillance System (BRFSS)]
5Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, et.al. and the National High Blood Pressure Education Program Coordinating
Commitee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Hypertension. Dec 2003;42:1206-1252.
12 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
- Assisting primary care clinics to send targeted
mailings to patients who have not had their
low-density lipoprotein (LDL) levels checked
within the past year.
- Conducting “Take Control” campaigns and
clinic-based interventions that encourage
Montanans to control their cholesterol levels
and blood pressure.
LEAD AGENCY: Montana Cardiovascular
• Promote the recommended standards of care for
adults with diabetes by:
- Encouraging cholesterol quality improvement
projects in primary care settings focusing on
patients with diabetes.
- Providing physicians feedback on results from
the cholesterol quality improvement projects.
- Promoting interventions with advancing
therapy and practice patterns to improve
control of patients’ cholesterol levels and
blood pressure. • Conduct blood pressure and cholesterol training
LEAD AGENCY: Montana Diabetes Project sessions for Community Health Representatives
• Promote control of diabetes through physician and tribal health workers on Montana
offices, outpatient clinics and diabetes educators. reservations to increase knowledge of CVD risk
Assist patients with control of their diabetes among American Indians.
through self-management goals and objectives. LEAD AGENCIES: Montana Cardiovascular
LEAD AGENCY: Montana Diabetes Project Health Program and Montana Diabetes Project
• Implement care profiles for patients with diabetes • Promote tobacco use cessation by:
in primary care practices, and send patients - Encouraging patients who smoke and are
customized letters containing recent lab values, at risk for heart disease and stroke to use
goals for those values, and recommended testing the Montana Tobacco Quit Line
LEAD AGENCY: Montana Diabetes Project - Providing evidence-based adult and youth
• Pilot the Primary Prevention Quality Care cessation services.
Management System (computer-based - Coordinating with the American Indian
registry) with selected health care providers to Tobacco Work Group to provide culturally
monitor metabolic syndrome, pre-diabetes and appropriate education to all health care
cardiovascular risk factors including high blood providers who serve American Indian groups.
pressure and elevated cholesterol levels. LEAD AGENCY: Montana Tobacco Use
LEAD AGENCY: Montana Diabetes Project Prevention Program
HeaLtHcare goaL 2 - Promoting hospital use of standing orders,
clinical pathways and discharge instructions
Improve the care of patients who have been when caring for patients who have had a stroke.
hospitalized with a heart attack or stroke. - Promoting hospital use of guidelines from the
Brain Attack Coalition and American Stroke
oBjective 2: Association upon discharge of patients who
have had a stroke.
A. By 2010, increase the number of American LEAD AGENCIES: Montana Cardiovascular
Association of Cardiovascular and Pulmonary Health Program and Stroke Workgroup
Rehabilitation (AACVPR) certified cardiac
rehabilitation programs from 7 to 9. [measured • Develop a state stroke initiative to:
by cardiac rehabilitation survey] - Enhance collaboration and networking among
B. By 2010, increase the number of Joint hospitals.
Commission on Accreditation of Healthcare - Provide continuing education opportunities
Organizations (JCAHO) certified primary stroke and assist community hospitals with assessing/
centers from 2 to 4. [measured by JCAHO treating stroke patients and sharing treatment
C. Increase the percentage of Montana hospitals - Investigate the use of telehealth to assist rural
with written tissue plasminogen activator (tPA) healthcare providers in acute management of
protocols for treating stroke patients, when stroke patients.
appropriate, from 67% in 2004 to 75% in 2010. - Promote consistent use of a stroke screening
[measured by hospital assessment] tool by EMS personnel.
- Implement a statewide stroke protocol for EMS
- Reach consensus on a statewide data registry.
• Develop a statewide quality improvement
program for outpatient cardiac rehabilitation LEAD AGENCY: Stroke Workgroup and
programs. Montana Cardiovascular Health Program
• Provide “state of the art” cardiovascular disease
LEAD AGENCIES: Montana Association of
Continuing Medical Education/continuing
Cardiovascular and Pulmonary Rehabilitation and
education to health professionals via annual
Montana Cardiovascular Health Program
conferences such as the Cardiovascular Health
• Develop a coordinated approach to improve the Summit, the Mining City Cardiovascular
care of patients who have had a stroke by: Conference, and the Yellowstone Regional Stroke
- Using standardized indicators for performance
measurement. LEAD AGENCIES: Montana Cardiovascular
Health Program, St. James Healthcare, and St.
- Establishing continuity of care procedures
between large facilities and smaller community
14 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
• Promote hospital policies to ensure that patients • Develop community-specific Secondary
who are admitted for a heart attack or stroke Prevention Resource Guides for patients who have
are prescribed a statin or other cholesterol- had a heart attack or stroke.
lowering drug. LEAD AGENCY: Montana Cardiovascular
LEAD AGENCIES: Stroke Workgroup, Montana Health Program
Cardiovascular Health Program, and hospitals • In cooperation with Billings Area Indian Health
collecting heart attack indicator data Service, provide surveillance and enhance
• Assist hospitals, particularly Critical Access awareness of the importance of secondary
Hospitals, in the care of heart attack patients prevention of heart disease.
upon admission and discharge. LEAD AGENCY: Montana Cardiovascular
LEAD AGENCY: Mountain-Pacific Quality Health Program
c o MMunity coMMunity goaL 1
Rapid response to a heart attack or stroke can spell Improve community awareness of heart
the difference between survival, disability, and death. attack and stroke signs/symptoms and risk
Educating community members to recognize the factors, and decrease the time between
symptoms of heart attack and stroke helps to ensure onset of symptoms and treatment of heart
that victims receive or seek care as quickly as possible. attack or stroke.
By working with communities, public health agencies
can effectively reach priority populations and link oBjective 1:
those at high risk for heart disease and stroke with
the appropriate healthcare system. Local groups are A. Increase the number of Montana counties
positioned to engage community members because participating in the heart attack signs and
they understand the unique character of their town symptoms public awareness campaigns from 1
and the type of outreach that may be more effective. in 2005 to 4 in 2010.
These local groups can also enhance heart disease and B. Increase the percentage of adults in Montana
stroke prevention activities by helping to raise their who can correctly identify 4 or more signs and
community’s awareness of signs and symptoms, risk symptoms of heart attack from 77% in 2003 to
factors and the need to use 911. 82% in 2009. [measured by BRFSS]
See Appendix B for the American Heart Association C. Increase the percentage of adults 45 years and
warning signs of heart attack and stroke. older who can correctly identify 3 or more heart
attack signs and symptoms using a modified
BRFSS open-ended heart attack module from
58% in 2005 to 65% in 2006. [measured by
• Expand the DPHHS heart attack signs and
symptoms campaigns to additional communities.
LEAD AGENCY: Montana Cardiovascular
• Increase awareness that cardiovascular disease
is also a woman’s disease, by supporting and
implementing the American Heart Association’s
guidelines for preventing heart disease and stroke
in women that are based on a woman’s individual
LEAD AGENCIES: American Heart Association
and Montana Cardiovascular Health Program
6 Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N, et.al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women.
16 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
oBjective 2: • Support Emergency Medical Dispatch (EMD)
training and protocols to ensure emergency
A. Increase the number of Montana counties coding and management of stroke and heart
participating in the stroke public awareness attack-related 911 calls.
campaigns from 2 in 2005 to 5 in 2010.
B. Increase the percentage of adults in Montana LEAD AGENCIES: Montana Cardiovascular
who can correctly identify 4 or more signs and Health Program and Department of
symptoms of stroke from 75% in 2003 to 80% Administration Public Safety Services Bureau
in 2009. [measured by BRFSS] • Promote Enhanced 911 coverage throughout
C. Increase the percentage of adults 45 years and Montana.
older who can correctly identify 3 or more signs LEAD AGENCIES: EMS Section of DPHHS,
and symptoms of stroke using a modified BRFSS American Heart Association, and Department of
open-ended stroke module from 39% in 2005 to Administration Public Safety Services Bureau
44% in 2006. [measured by community surveys]
• Decrease the percentage of Montana adults who
• Expand the DPHHS stroke signs and symptoms smoke cigarettes from 20% in 2003 to 12% in
health education projects to additional 2010. [measured by BRFSS]
communities. Create culturally appropriate
educational messages for American Indian StrategieS:
communities. • Increase the number of callers to the Montana
LEAD AGENCY: Montana Cardiovascular Tobacco Quit Line (1-866-485-QUIT).
Health Program LEAD AGENCY: Montana Tobacco Use
oBjective 3: Prevention Program
• Promote the Quit Line by partnering with
• Increase the percentage of adult Montanans who Emergency Food Programs; the Special
are aware of the need to call 911 if they thought Supplemental Nutrition Program for Women,
someone was having a heart attack or stroke from Infants, and Children and other groups that
85% in 2003 to 89% in 2009. [measured by consistently meet with the general population.
LEAD AGENCY: Montana Tobacco Use
StrategieS: Prevention Program
• Promote AED placement in community sites such • Work with local and state tobacco advocacy
as malls, local airports, and community centers. groups to promote tobacco-free environments in
LEAD AGENCIES: Emergency Medical Services
(EMS) Section of DPHHS and Montana LEAD AGENCY: American Heart Association
Cardiovascular Health Program and Montana Tobacco Use Prevention Program
• Promote legislation establishing a statewide AED • Support sufficient funding of community tobacco
registry. prevention programs.
LEAD AGENCIES: American Heart Association LEAD AGENCY: Montana Tobacco Use
and Montana Cardiovascular Health Program Prevention Program
W or KS ite
PoLicy anD environMentaL cHange in
The workplace is an ideal location to make policy and
environmental changes that promote cardiovascular
health. However, according to surveys conducted by
the Montana Cardiovascular Health Program, few
Montana worksites have made such changes. Barriers
include the cost of establishing and maintaining
wellness programs, the need to inform executives
about wellness issues, and lack of an on-site champion
or management support.
Policy examples specific to cardiovascular disease
• Providing insurance coverage for rehabilitation
services after employees have a heart attack
• Providing coverage for tobacco cessation therapies.
• Offering screening and follow-up with a provider
for treatment of high blood pressure and elevated
Environmental examples include:
• Automated External Defibrillators (AEDs) within
close proximity and available staff trained in
cardiopulmonary resuscitation (CPR) and use
of AEDs in the event an employee suffers a
• Signage posted on stroke risk factors.
• Tobacco-free work environments and surrounding
Policy and environmental supports to reduce risk
of heart disease and stroke can improve employee
health, impact employee healthcare costs, decrease
absenteeism, and positively affect the employer’s
18 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
WorKSite goaL 1 • Provide health risk assessments, resources, and
toolkits to at least 20 employers across
Engage Montana employers in providing the state.
policies, environmental conditions, LEAD AGENCIES: Governor’s Council
programs, benefits, and strategies that on Worklife Wellness and the Montana
reduce the risk of heart disease and stroke Cardiovascular Health Program
among their employees. • Acknowledge employers that offer comprehensive
cardiovascular risk reduction programs through
recognition by the Governor’s Council on
Worklife Wellness annual awards program.
A. By 2010, increase from 54% to 59% the LEAD AGENCY: Governor’s Council on
percentage of Montana’s survey respondents Worklife Wellness
(>250 employees) with wellness component
• Encourage tribal organizations to consider clean
mean score of ≥5. [measured by survey of
indoor air policies.
Montana’s larger businesses]
LEAD AGENCY: Montana Tobacco Use
B. By 2010, increase from 41% to 44% the
percentage of Montana’s survey respondents
(<250 employees) with wellness component oBjective 2:
mean score of ≥3. [measured by survey of
Montana’s smaller businesses] By 2006, conduct an assessment of wellness offerings
in 400 small businesses (<250 employees), and
C. By 2010, increase by 10% the number of publish a report to complement the previous worksite
Montana employers that are implementing wellness survey of Montana’s larger employers.
worksite risk reduction programs with an
emphasis on blood pressure or cholesterol. StrategieS:
[Baseline data is calculated from 2000 and 2005
worksite surveys of Montana businesses.] • Identify the most common cardiovascular
risk reduction components offered by smaller
StrategieS: businesses and the challenges they encounter in
• Engage government, nonprofit, and for-profit providing and maintaining those services.
employers in providing cardiovascular risk LEAD AGENCY: Montana Cardiovascular
reduction programs that: Health Program
- Offer employees screenings, referrals, and • Using survey results, collaborate with two
follow-up with providers to control blood worksites to conduct a pilot and address
pressure and cholesterol levels. small business barriers to implementing a
- Place AEDs in the worksite and train staff in cardiovascular risk reduction program. Promote
CPR and usage of AEDs. realistic measures that smaller worksites can take
to reduce employees’ blood pressure and blood
- Increase employees’ awareness of the signs and cholesterol risk.
symptoms of a heart attack and stroke and the
need to call 911 immediately. LEAD AGENCY: Montana Cardiovascular
- Promote the Tobacco Quit Line for employees.
LEAD AGENCY: Montana Cardiovascular
oBjective 3: oBjective 4:
By 2007, survey Montana insurance companies to Using results from the 2007 insurance company
assess coverage of primary and secondary preventive assessment, by 2010, increase by 10% the number
cardiovascular services and medications for employees of insurance companies providing comprehensive
who smoke, have high blood pressure, elevated coverage and reimbursement for heart disease and
cholesterol levels, or who have had a heart attack stroke prevention and treatment.
• Encourage Montana worksites to provide health
• Determine barriers to and incentives for providing insurance coverage of heart disease and stroke-
adequate insurance coverage of preventive related primary and secondary prevention services
cardiovascular services. including tobacco cessation therapies and Medical
LEAD AGENCY: Montana Cardiovascular
Health Program LEAD AGENCIES: Governor’s Council
on Worklife Wellness and the Montana
Cardiovascular Health Program
• Promote adequate insurance coverage of
medications used for treatment of high blood
pressure, high cholesterol, heart disease, and
LEAD AGENCY: Montana Cardiovascular
20 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
Progra M e vaLuation
Program evaluation is important Program evaluation will assist in
and necessary to improve answering several broad questions:
program operations, measure
program achievement or progress, 1) Is the intervention reaching
demonstrate accountability to the target population?
stakeholders, manage program 2) Is it being implemented in
resources, focus program the ways specified in the
priorities, and advocate for the evaluation plan?
program. CDC defines evaluation
as the systematic collection of 3) Is it effective?
information about the activities,
The goals, objectives, and
characteristics and outcomes of
strategies established in this
programs to make judgments
plan will help guide Montana’s
about the program, improve
Cardiovascular Health Program to
program effectiveness; and/or
reduce cardiovascular disease.
inform decisions about future
programming. It will be integrated
into all program components
(e.g., interventions, training and
technical assistance, strategic Engage
partnerships, etc.). stakeholders
Montana’s evaluation plan is based
Ensure use Describe
on CDC’s evaluation framework, the program
a practical tool designed to lessons learned Utility
summarize and organize the Feasibility
essential elements of any program Propriety
evaluation.7 (Figure 8) This Accuracy Focus the
evaluation plan will include both Justify evaluation
process and outcome measures
and will give an overall picture of
planned evaluation activities in Gather credible
order to assess the effectiveness evidence
of the CVH Program and so that
required staff time and resources
Figure 8. Program Evaluation Approach (circular)
can be identified.
7 Centers for Disease Control and Prevention. State Heart Disease and Stroke Prevention Program: Evaluation Concepts. Atlanta, GA:US
Department of Health and Human Services, Center for Disease Control and Prevention, 2004.
g LoSS ary
AED ................................. Automated External Defibrillator
AHA ................................ American Heart Association
AI...................................... American Indians
ASA.................................. American Stroke Association
BRFSS ............................. Behavioral Risk Factor Surveillance System
CDC ................................ Centers for Disease Control and Prevention
CPR ................................. Cardiopulmonary Resuscitation
CVD ................................ Cardiovascular Disease
DPHHS ........................... The Montana Department of Public Health and Human Services
ED ................................... Emergency Department
EMD................................ Emergency Medical Dispatch
EMS ................................. Emergency Medical Services
HBP................................. High Blood Pressure
IHS .................................. Indian Health Service
Obesity ............................ Adults with a Body Mass Index (BMI) at or above 30.0 kg/m2
Quality of Life.................. This phrase is used to describe a general sense of happiness and satisfaction with our
lives and environment. General quality of life encompasses all aspects of life,
including health, recreation, culture, rights, values, beliefs, aspirations, and the
conditions that support a life containing these elements.8
tPA .................................... Tissue plasminogen activator
YRBS ................................ Youth Risk Behavior Survey
8 U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. With Understanding and Improving Health and Objectives for
Improving Health. 2 vols. Washington DC:U.S. Government Printing Office, November 2000, page 10.
22 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
a PP en Dix a: ProgreS S o n M o n ta n a
c arDiova ScuLar Di Se aS e P r e v e n t i o n a nD
c ontro L PLan 2000
The Montana Cardiovascular The greatest achievements include Market Nutrition Program;
Disease Prevention and Control the following: expanding the number of
Plan 2000 included objectives and schools offering the School
strategies in the following areas: • Tobacco: creating policies on Breakfast Program; assuring
smoke-free environments; that menu standards for meals
• tobacco use prevention increasing the tax on cigarettes; in correctional facilities follow
• reduction of hypertension and establishing a Quit Line. national dietary standards;
(high blood pressure) and • Hypertension: monitoring promoting 5 A Day in
cholesterol blood pressure control and communities through mini-
• reduction of overweight and hypertension treatment for grants; continuing Eat Right
obesity patients with diabetes. Montana’s “Healthy Families”
• Secondary prevention: nutrition and physical
• improvement in physical
developing community- activity media campaign; and
activity and nutrition
specific guides on secondary increasing the number of
For the first three years of prevention resources for community gardens through
the plan, the Cardiovascular patients recovering from heart mini-grants.
Health Program addressed attack or stroke; creating a These accomplishments were
health promotion strategies and directory on free and reduced only possible because multiple
conducted statewide policy and cost medications for indigent programs and agencies at the local
environmental assessments. In the patients. and state level clearly focused on
past two years, the Cardiovascular • Physical activity: expanding the issues to advocate for a policy
Health Program gradually shifted “Walk to School Day” change or to implement a project.
its focus to blood pressure, statewide and developing a A similar mobilization of resources
blood cholesterol, heart disease physical activity video for and a commitment to take action
and stroke to match the revised older American Indians. are needed to fulfill the vision of
priorities of CDC’s Division the 2006–2010 Montana Heart
for Heart Disease and Stroke • Nutrition: obtaining state
Disease and Stroke State Plan.
Prevention. funding for the WIC Farmers’
Partners such as the American
Heart Association, Montana
Tobacco Use Prevention Program,
Montana Diabetes Project, Eat
Right Montana coalition, and the
Montana Dietetic Association
played a vital role in implementing
selected 2000-2005 cardiovascular
state plan strategies.
a P Pen Dix B: aH a Warni n g S i g nS
The following information is from the American Heart Association Web site.9 Coronary heart disease is America’s No.
1 killer. Stroke is No. 3 and a leading cause of serious disability. That’s why it’s so important to reduce your risk factors,
know the warning signs, and know how to respond quickly and properly if warning signs occur.
Some heart attacks are sudden and intense—the “movie heart attack,” where no one doubts what’s happening. But most
heart attacks start slowly, with mild pain or discomfort. Often people affected aren’t sure what’s wrong and wait too long
before getting help. Here are signs that can mean a heart attack is happening:
• Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes,
or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain.
• Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the
back, neck, jaw or stomach.
• Shortness of breath. May occur with or without chest discomfort.
• Other signs. These may include breaking out in a cold sweat, nausea or lightheadedness.
If you or someone you’re with has chest discomfort, especially with one or more of the other signs, don’t wait longer than a
few minutes (no more than 5) before calling for help. Call 9-1-1... Get to a hospital right away.
Calling 9-1-1 is almost always the fastest way to get lifesaving treatment. Emergency medical services staff can begin
treatment when they arrive—up to an hour sooner than if someone gets to the hospital by car. Staff members are also
trained to revive someone whose heart has stopped. Patients with chest pain who arrive by ambulance usually receive faster
treatment at the hospital, too.
Cardiac arrest strikes immediately and without warning. Here are the signs:
• Sudden loss of responsiveness. No response to gentle shaking.
• No normal breathing. The victim does not take a normal breath when you check for several seconds.
• No signs of circulation. No movement or coughing.
If cardiac arrest occurs, call 9-1-1 and begin CPR immediately. If an automated external defibrillator (AED) is available
and someone trained to use it is nearby, involve them.
The American Stroke Association says these are the warning signs of a stroke:
• Sudden numbness or weakness of the face, arm or leg, especially one side of the body.
• Sudden confusion, trouble speaking or understanding.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble walking, dizziness, loss of balance or coordination.
• Sudden, severe headache with no known cause.
If you or someone with you has one or more of these signs, don’t delay! Immediately call 9-1-1 or the emergency medical
services (EMS) number so an ambulance (ideally with advanced life support) can be sent for you. Also, check the time so
you’ll know when the first symptoms appeared. It’s very important to take immediate action. If given within three hours of
the start of the symptoms, a clot-bursting drug can reduce long-term disability for the most common type of stroke.
9 For more information, see www.americanheart.org/presenter.jhtml?identifier=3053#Heart_Attack
24 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
aPP en Dix c: cLaSSi Fi c at i o n a nD M a n a g eM e n t
oF BLoo D PreSS ure Fo r a Du Lt S
The following table is from the National High Blood Pressure Education Program, the Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, US Department of Health and
Human Services, National Institutes of Health, National Heart, Lung and Blood Institute.10
initiaL Drug tHeraPy
BP SBP* DBP* LiFeStyLe
cLaSSiFication MMHg MMHg MoDiFication WitH coMPeLLing
Normal < 120 and <80 Encourage Drug(s) for
Prehypertension 120-139 or 80-89 Yes drug indicated
Stage 1 Hypertension 140-159 or 90-99 Yes Thiazide-type Drug(s) for
diuretics for most. the compelling
May consider ACEI, indications.*** Other
ARB, BB, CCB, or antihypertensive
combination. drugs (diuretics,
Stage 2 Hypertension > 160 or > 100 Yes Two-drug ACEI, ARB, BB,
combination for CCB) as needed.
diuretic and ACEI
or ARB or BB or
DBP: diastolic blood pressure
SBP: systolic blood pressure
Drug abbreviations: angiotensin converting enzyme inhibitor (ACEI); angiotensin receptor blocker (ARB);
beta-blocker (BB); calcium channel blocker (CCB).
* treatment determined by highest blood pressure category.
** Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
*** Treat patients with chronic kidney disease or diabetes to blood pressure goal of 130/80 mmHg.
10 For additional information, see www.nhlbi.nih.gov/guidelines/hypertension/express.pdf
a P Pen Dix D: at P iii cL aS Si F i c at i o n oF L D L ,
t o taL,an D HDL cH o LeS t e r oL (M g /DL )
The following table is from the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and
Treatment of High Blood Cholesterol in Adults.11
LDL Cholesterol Total Cholesterol HDL Cholesterol
< 100 Optimal <200 Desirable <40 Low
100-129 Near optimal/ 200-239 Borderline high >60 High
130-159 Borderline high >240 High
>190 Very high
11 For more information, see www.nhlbi.nih.gov/guidelines/cholesterol/atp3xsum.pdf
26 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
aPP en Dix e: Key StaK eHo L De rS
”Coming together is a beginning. Keeping together is progress. Working together is success.”
On October 7, 2004, the Montana Cardiovascular Disease/Obesity Task Force began the process of formulating a
comprehensive plan that evolved into two state plans – one on heart disease and stroke and one on obesity, nutrition, and
physical activity. Joint Task Force and work group members involved in the planning process represent a broad spectrum of
key stakeholders interested in the prevention and control of heart disease, stroke, and obesity.
Task force members and partners agreed to:
• Develop a five-year heart disease and stroke state plan that includes specific measurable outcomes and strategies;
• Participate throughout all phases of the planning process;
• Identify, implement, and evaluate specific strategies to affect outcomes with state, community and individual partners;
• Commit resources (e.g. skills, time, etc.) to the development of the plan.
Work group participants identified chairs and recorders as well as a schedule of meetings to take place during the months
of October, November, and December. Tasks to be accomplished through those meetings included the following:
• Define the overarching goal of each work group, in keeping with the identified goals of the Heart Disease and Stroke
• Develop a short overview of the particular domain, giving a brief description of opportunities and challenges.
• Develop two to five SMART12 objectives related to the overarching goal.
• Identify the agency or person that is committed to move the strategy forward.
A Native American subcommittee met on January 7, 2005 to develop an over-arching goal, objectives and strategies
pertinent to all American Indians in Montana. The group identified three major themes to be woven into all areas of the
state plan, as follows:
• Building a legacy of health and wellness for our children and grandchildren;
• Eliminating disparities in health care throughout the state of Montana; and
• Healing historic and emotional issues pertinent to American Indians that create “heavy hearts” and broken lives.
Each work group developed a draft section of the plan and, on January 26, 2005, the Task Force met for a second time
to listen and provide feedback regarding these draft sections. This input was then gathered into a first draft of the entire
plan and disseminated to all task force and work group members for final comment. These comments were then included
in the plan.
12 SMART objectives are: Specific/Single outcome; Measurable, Achievable, Related/Reasonable, and Time bound. Develop strategies for each of
cvD/oBeSity Prevention taSK Force anD WorK grouP MeMBerS
A listing of members of the Task Force, State Plan Work Groups, and the Native American subcommittee is
Anne Burnett, MN, APRN, FNP Christopher Mast, DDS
Benefis Healthcare Montana Dental Association
Great Falls Helena
Mary Ann Carlson, MD Mark Meredith, PharmD
MT Chapter, American Academy of Pediatrics St. Peter’s Hospital
Columbia Falls Helena
Blaise Favara, MD Linda Olsen, RN, CHE
South Valley Pediatrics Billings Clinic
Sharon Hecker, MD Brad Roy, PhD, CHE, FACSM
St. James Healthcare The Summit
Butte Kalispell Regional Medical Center
Dwight Hiesterman, MD
Mountain-Pacific Quality Health Foundation Donna Russell-Cook
Helena St. Vincent Healthcare
Jacque Jakovac, RN, MA
Blue Cross Blue Shield of Montana Christopher Schon, MPA, FACMPE
Helena Billings Clinic
Diane Jones, APRN, FNP
Wheatland Memorial Hospital and Candie Stearns, MN, FNP
Nursing Home Montana Migrant Council
Greg Lind, MD Kristin Thompson, RHIA QM/HEDIS
Missoula Blue Cross Blue Shield of Montana
Cathy Lisowski, MS, ES
The Summit Robert E. Wynia, MD
Kalispell Regional Medical Center Great Falls
Dorothy Gohdes, MD Dayle Hayes, MS, RD
Cardiovascular Health Program Consultant Nutrition for the Future, Inc.
Albuquerque, New Mexico Billings
28 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
DePartMent oF PuBLic HeaLtH anD HuMan ServiceS
Kathy Brenden Michael McNamara, MS
Child and Adult Care Food Program Cardiovascular Health Program
Dennis Cox Carrie Oser, MPH
Child and Adolescent Health Program Cardiovascular Health Program
Crystelle Fogle, MBA, MS, RD Brenda Peppers
Cardiovascular Health Program Child and Adult Care Food Program
Georgiana (George) Gulden, RN, BSN Lori Rittel, MS, RD
Tobacco Use Prevention Program Special Supplemental Nutrition Program for Women,
Infants and Children (WIC)
Todd Harwell, MPH
Chronic Disease Prevention & Health Promotion Marni Stevens, MS, RD
Steven Helgerson, MD, MPH Great Falls
State Medical Officer
Liz Johnson, RNCNP Tobacco Use Prevention Program
Montana Diabetes Project
otHer Montana governMent agencieS
Diane Arave Cathy Kendall
Department of Administration Office of Public Instruction
State Employee Benefits
Christine Emerson, MS, RD Department of Transportation
Office of Public Instruction
LaDonna Grotbo Fish, Wildlife & Parks
Department of Administration
State Employee Benefits
LocaL HeaLtH DePartMentS
Laura Behenna Mary Pittaway, MA, RD
Lewis & Clark City-County Health Department Missoula City-County Health Department
Ellen Brown, MPA Lynette Van Aken
Missoula City-County Health Department Flathead County Health Department
Debbie Hedrick, MHA Ellen Wangsmo, MPH
Yellowstone City-County Health Department Yellowstone City-County Health Department
inDian HeaLtH Service, triBaL HeaLtH anD urBan inDian centerS
Lena Belcourt Mary Ellen LaFramboise
Rocky Boy’s Health Board Blackfeet Tribe
Box Elder Browning
Bonnie Bentley Margaret Mall, RD, CDE, Bc.ADN
Fort Belknap Tribal Health Diabetes Program OSK Tribal Health
Lori Bird In Ground Tom Mexican Cheyenne
Crow Tribal Health Community Health
Crow Agency Northern Cheyenne Tribal Nation
Lee Ann B. Johnson, MPH
Billings Area Indian Health Service Helen Pipe, RN, BSN, CDE
Billings Fort Peck Tribal Health Diabetes Program
Tracy Burns, MS, RD
Chippewa-Cree Health Center Manuallea Realbird-Masteth
Box Elder Crow Tribal Health
Missoula Urban Indian Center LuMary Spang
Missoula Crow Tribal Health
Charlene Johnson, MPH, RD, CDE
Indian Health Service
Cliff Christian Gloria Lambertz, EdD
American Heart Association Montana Assoc. of Health, PE, Recreation & Dance
Pacific Mountain Affiliate/Advocacy (MAHPERD)
Suzie Eades Minkie Medora, MS, RD
Big Sky State Games/Shape Up Montana/Big Sky Fit Kids Food Policy Council
Billings Montana Food Bank Network
Pat Hennessey, MS, RD
Healthy Mothers, Healthy Babies – Montana Coalition Karen Sanford-Gall
Helena Big Sky State Games/Shape Up Montana
Dan Keith MBA, RN
Home Health of Montana
30 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
Suzanne Binne-Huse, RD
Missoula Head Start
Montana coLLegeS anD univerSitieS
Ninia Baehr, MA, RN Lynn Hellenga, RD
Montana Nutrition and Physical Activity Program Montana Nutrition and Physical Activity Program
Montana State University Bozeman
Katie Bark, RD Kathleen Humphries
Team Nutrition University of Montana, Rural Institute
Montana State University Missoula
Janet Belcourt, MPH Mary Miles, PhD
Diabetes Education in Tribal Schools Montana State University
Stone Child College Bozeman
Chris Clasby, MSW Montana State University-Billings
Montana Disability and Health Program
University of Montana, Rural Institute Erica Parker
Missoula University of Montana, Rural Institute
Cathy Costakis, MS
Montana Nutrition and Physical Activity Program Lynn Paul, EdD, RD
Montana State University Montana State University Extension
Phyllis Dennee, MS, CFCS Mary Stein, MS
Montana State University Extension Montana State University
Steve Gaskill Patti Steinmuller, MS, RD
University of Montana Montana State University
Donna Greenwood, RN, MSN Meg Ann Traci, PhD
Carroll College University of Montana, Rural Institute
Dan Heil, PhD, FACSM
Montana State University
Jason Gleason, MS, FNP-C Emily Matt Salois, MSW, ACSW
Christopher Lepore Pete Shatwell
Johnson & Johnson TwoMedicine Health and Financial Fitness
a P Pen Dix F: Logic Mo DeL
Capacity Building Update and publish
Governor’s State Plan
EMS Section capacity
AHA/ASA Identify priority
populations Develop culturally
Association of Complete policy strategies
Cardiovascular and environmental
and Pulmonary population-based
IHS and technical
32 Heart Di S eaS e a nD S t r oK e P L a n 2 0 0 6 – 2 0 1 0
Short Term Intermediate Long Term Long Term
of 911 and EMS
having a stroke Increase knowledge
or heart of 911 use at the
Increase attack state level Decrease
community prevalence of
awareness of heart disease,
stroke/heart stroke and CVD
attack signs Decrease time risk factors
& symptoms from symptom Pass 911 legislation
onset to ED and AED registry
arrival for stroke legislation
Increase patients Decrease heart
community disease and
awareness of stroke-related
cholesterol Implement death &
control policy and disability
environmental the state level
Establish change in
system Improve control
Improve care of stroke
of heart disease
patients with disparities
and stroke risk
Facilitate heart disease, factors
statewide stroke and
stroke initiative cardiovascular
risk factors in
for heart disease-
and conduct Implement
cardiovascular policy and
risk reduction environmental
pilot change in