Resources
Vital Knowledge
This page is for anyone who wants to know more about the work. Collaborative members looking for tools and training, community residents looking for local care, partners wanting to understand the evidence behind this work, and organizations interested in replicating what these counties are building.
Understanding the Work
The Georgia Cardiovascular Health Initiative is grounded in a community-led, data-informed approach to cardiovascular health. If you’re new to this work or want to understand the framework behind it, start here.
- What is the Plan-Do-Study-Act (PDSA) cycle? [https://www.ihi.org/resources/how-to-improve]
- About the CDC Innovative Cardiovascular Health Program [https://dph.georgia.gov/chronic-disease-prevention/heart-disease/heart-disease-prevention]
- CDC Cardiovascular Health Program Logic Model [https://dph.georgia.gov/document/document/cvh-logic-modelpdf/download]
Community Needs Assessments
Every county Collaborative built its strategy on a census-tract level Community Health Needs Assessment. These assessments take a deep look at who carries the highest burden of cardiovascular disease, what social conditions drive that burden, and where community-led intervention can have the greatest effect. These were the foundation of this initiative.
- Clayton County Community Health Needs Assessment [link to PDF]
- Macon County Community Health Needs Assessment [link to PDF]
- Muscogee County Community Health Needs Assessment [link to PDF]
- Randolph County Community Health Needs Assessment [link to PDF]
Nutrition and Food Access
Food access is heart health. Two of our four active Collaboratives have built their programs around this idea. In Muscogee County, the Good Health Market pairs fresh produce with on-site blood pressure screenings, and residents enrolled in Cooking Matters nutrition classes have seen measurable blood pressure improvement. In Clayton County, fresh food distribution is integrated into every Heart Hub event. Finding and accessing affordable, nutritious food is one of the most direct tools we have for reducing cardiovascular risk in the communities we serve.
- Cooking Matters — Free nutrition education classes available through the Muscogee Collaborative [https://cookingmatters.org]
- Wholesome Wave Georgia — produce prescription and food access programs in Georgia [https://wholesomewavegeorgia.org]
- Georgia SNAP Education — nutrition education and healthy eating support [https://dfcs.georgia.gov/services/snap/snap-ed]
- USDA Food and Nutrition Service — SNAP information and eligibility [https://www.fns.usda.gov/snap]
The Healthy Heart Ambassador Program
One of the most powerful tools in this initiative is the neighbor. The Healthy Heart Ambassador (HHA) Program trains community members to share heart health information in their own neighborhoods. These ambassadors learn to discuss blood pressure, healthy eating, and stress management, and how to connect people to local care. They work through churches, barbershops, schools, and community events, showing up in the spaces where people already trust each other. The program is currently active in Clayton, Muscogee, and Randolph Counties. Interested in becoming an Ambassador? Contact your county Collaborative.
- Million Hearts — National HHA Program Overview [https://millionhearts.hhs.gov]
- Virginia HHA Program — A State Example [https://www.vdh.virginia.gov/heart-disease/virginia-healthy-heart-ambassador-blood-pressure-self-monitoring-program-hha-bpsm/]
- Texas HHA Implementation Study — BMC Health Services Research [https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-024-11485-z]
Heart Health Resources
- American Heart Association — Understanding Blood Pressure [https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings]
- CDC — Blood Pressure Basics [https://www.cdc.gov/high-blood-pressure/measure/index.html]
- Find a health center near you — HRSA Health Center Finder [https://findahealthcenter.hrsa.gov/]
General Resources
- Find Help GA — Search for food, housing, utilities, and health resources near you [https://findhelpga.org]
- Georgia Access — individual market health insurance options in Georgia [https://georgiaaccess.gov]
- Georgia Rural Health — telehealth and rural health access programs [https://www.georgiaruralhealth.org]
Research and Evidence
These publications provide context for strategies that can be used in this important work:
- Meernik C, Leonard D, Shuval K, et al. Midlife Cardiorespiratory Fitness and Healthy Aging: An Observational Cohort Study. Journal of the American College of Cardiology.[https://www.jacc.org/doi/10.1016/j.jacc.2026.02.5122]
- Hager K, et al. Impact of Produce Prescriptions on Diet, Food Security, and Cardiometabolic Health Outcomes: A Multisite Evaluation of 9 Produce Prescription Programs in the United States. Circulation: Cardiovascular Quality and Outcomes. 2023. [https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.122.009520]
- Lynch EB, et al. Heart 2 Heart: Pilot Study of a Church-Based Community Health Worker Intervention for African Americans with Hypertension. Prevention Science. 2023. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11133067/]
- Bush K, et al. Unsung Heroes in Health Education and Promotion: How Community Health Workers Contribute to Hypertension Management. Frontiers in Public Health. 2023. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9996176/]
Vital Knowledge
This page is for anyone who wants to know more about the work. Collaborative members looking for tools and training, community residents looking for local care, partners wanting to understand the evidence behind this work, and organizations interested in replicating what these counties are building.
Understanding the Work
The Georgia Cardiovascular Health Initiative is grounded in a community-led, data-informed approach to cardiovascular health. If you’re new to this work or want to understand the framework behind it, start here.
- What is the Plan-Do-Study-Act (PDSA) cycle? [https://www.ihi.org/resources/how-to-improve]
- About the CDC Innovative Cardiovascular Health Program [https://dph.georgia.gov/chronic-disease-prevention/heart-disease/heart-disease-prevention]
- CDC Cardiovascular Health Program Logic Model [https://dph.georgia.gov/document/document/cvh-logic-modelpdf/download]
Community Needs Assessments
Every county Collaborative built its strategy on a census-tract level Community Health Needs Assessment. These assessments take a deep look at who carries the highest burden of cardiovascular disease, what social conditions drive that burden, and where community-led intervention can have the greatest effect. These were the foundation of this initiative.
- Clayton County Community Health Needs Assessment [link to PDF]
- Macon County Community Health Needs Assessment [link to PDF]
- Muscogee County Community Health Needs Assessment [link to PDF]
- Randolph County Community Health Needs Assessment [link to PDF]
Nutrition and Food Access
Food access is heart health. Two of our four active Collaboratives have built their programs around this idea. In Muscogee County, the Good Health Market pairs fresh produce with on-site blood pressure screenings, and residents enrolled in Cooking Matters nutrition classes have seen measurable blood pressure improvement. In Clayton County, fresh food distribution is integrated into every Heart Hub event. Finding and accessing affordable, nutritious food is one of the most direct tools we have for reducing cardiovascular risk in the communities we serve.
- Cooking Matters — Free nutrition education classes available through the Muscogee Collaborative [https://cookingmatters.org]
- Wholesome Wave Georgia — produce prescription and food access programs in Georgia [https://wholesomewavegeorgia.org]
- Georgia SNAP Education — nutrition education and healthy eating support [https://dfcs.georgia.gov/services/snap/snap-ed]
- USDA Food and Nutrition Service — SNAP information and eligibility [https://www.fns.usda.gov/snap]
The Healthy Heart Ambassador Program
One of the most powerful tools in this initiative is the neighbor. The Healthy Heart Ambassador (HHA) Program trains community members to share heart health information in their own neighborhoods. These ambassadors learn to discuss blood pressure, healthy eating, and stress management, and how to connect people to local care. They work through churches, barbershops, schools, and community events, showing up in the spaces where people already trust each other. The program is currently active in Clayton, Muscogee, and Randolph Counties. Interested in becoming an Ambassador? Contact your county Collaborative.
- Million Hearts — National HHA Program Overview [https://millionhearts.hhs.gov]
- Virginia HHA Program — A State Example [https://www.vdh.virginia.gov/heart-disease/virginia-healthy-heart-ambassador-blood-pressure-self-monitoring-program-hha-bpsm/]
- Texas HHA Implementation Study — BMC Health Services Research [https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-024-11485-z]
Heart Health Resources
- American Heart Association — Understanding Blood Pressure [https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings]
- CDC — Blood Pressure Basics [https://www.cdc.gov/high-blood-pressure/measure/index.html]
- Find a health center near you — HRSA Health Center Finder [https://findahealthcenter.hrsa.gov/]
General Resources
- Find Help GA — Search for food, housing, utilities, and health resources near you [https://findhelpga.org]
- Georgia Access — individual market health insurance options in Georgia [https://georgiaaccess.gov]
- Georgia Rural Health — telehealth and rural health access programs [https://www.georgiaruralhealth.org]
Research and Evidence
These publications provide context for strategies that can be used in this important work:
- Meernik C, Leonard D, Shuval K, et al. Midlife Cardiorespiratory Fitness and Healthy Aging: An Observational Cohort Study. Journal of the American College of Cardiology.[https://www.jacc.org/doi/10.1016/j.jacc.2026.02.5122]
- Hager K, et al. Impact of Produce Prescriptions on Diet, Food Security, and Cardiometabolic Health Outcomes: A Multisite Evaluation of 9 Produce Prescription Programs in the United States. Circulation: Cardiovascular Quality and Outcomes. 2023. [https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.122.009520]
- Lynch EB, et al. Heart 2 Heart: Pilot Study of a Church-Based Community Health Worker Intervention for African Americans with Hypertension. Prevention Science. 2023. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11133067/]
- Bush K, et al. Unsung Heroes in Health Education and Promotion: How Community Health Workers Contribute to Hypertension Management. Frontiers in Public Health. 2023. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9996176/]
Funded By
The Centers for Disease Control National Cardiovascular Health Program
(CDC NOA_DP23_0004)
Implemented By
Mosaic Group
1122 Kenilworth Drive, Suite 313
Towson, MD 21204
(410) 852-4263
groupmosaic.com
Contact Us
Project Contact
Patsy Sarnor, MPH
patsy.sarnor1@dph.ga.gov
(470) 869-5911
Mosaic Group Contact
Marla Oros, MS, RN, FAAN
moros@groupmosaic.com
(410) 852-4263
© 2026 Georgia Cardiovascular Health Initiative.