Beating Stronger Every Year

The Georgia Cardiovascular Health initiative is rolling out across six high-burden Georgia counties in staged cohorts:

• Cohort 1 (launched 2024): Clayton and Muscogee Counties
• Cohort 2 (launched 2025): Randolph and Macon Counties
• Cohort 3 (launching 2026): Richmond and Dougherty Counties

These counties were identified using census-tract level data that showed some of the highest hypertension rates in the state, along with the social and structural conditions that drive those rates. Each county operates its own Heart Health Collaborative — a cross-sector group led by a local Community Champion organization that meets monthly, uses data to guide decisions, and includes residents with lived experience at the table. The Collaboratives come together through the Georgia Heart Health Learning Collaborative to share lessons learned, exchange resources, and strengthen one another’s work.

This site is the shared home of that work. It is designed for Collaborative members, partners, residents, and anyone who wants to understand what community-led cardiovascular health change looks like in Georgia.

Why Georgia, Why These Counties

The burden of heart disease in Georgia is neither uniform nor inevitable. Statewide data from the OASIS system showed that while Georgia overall faces heart disease rates above national averages, the disease concentrates most heavily in specific counties — and, within those counties, in specific neighborhoods and census tracts. It is there, where the burden is heaviest, that this initiative is focused.

The Georgia Context

Georgia’s cardiovascular disease burden is shaped by a combination of chronic risk factors, uneven access to primary care, and social conditions that make it harder for people to stay healthy. Statewide benchmarks from OASIS, PLACES, and County Health Rankings provide the baseline against which our county burdens stand out:

• • 1 in 3 Georgia adults (33.4%) has been diagnosed with hypertension — the most important modifiable risk factor for heart attack and stroke. (CDC PLACES / BRFSS, 2022–2024)
  • 9% of Georgia adults have high cholesterol, 4.0% have diagnosed coronary heart disease, and 3.3% have had a stroke. (CDC PLACES, 2022–2024)
  • Heart disease is a leading cause of death in Georgia, with an age-adjusted obstructive heart disease mortality rate of 67.9 per 100,000, a stroke mortality rate of 44.0 per 100,000, and a hypertensive heart disease mortality rate of 28.3 per 100,000. (Georgia OASIS, 2020–2024)
  • High blood pressure drives 436.6 ER visits per 100,000 Georgians each year — more than any other cardiovascular cause. (Georgia OASIS, 2020–2024)
  • 1,517 Georgians per primary care physician statewide — a ratio that is much worse in many of our participating counties. (County Health Rankings, 2025)
  • 6% poverty rate, 11.4% uninsured, and 6.3% of households without a vehicle statewide — the social conditions that shape whether good health is possible. (U.S. Census ACS, 2019–2023)

Nationally, Georgia sits within the CDC-recognized “Stroke Belt” — a band of Southeastern states with stroke mortality significantly above the U.S. average (CDC, Division for Heart Disease and Stroke Prevention). Within Georgia, the burden is heaviest in rural southwest Georgia, central Georgia, and pockets of the Atlanta metro where poverty, provider shortages, and food insecurity concentrate. These are many of the same areas that the Collaboratives operate within.

Beating Stronger Every Year

The Georgia Cardiovascular Health initiative is rolling out across six high-burden Georgia counties in staged cohorts:

• Cohort 1 (launched 2024): Clayton and Muscogee Counties
• Cohort 2 (launched 2025): Randolph and Macon Counties
• Cohort 3 (launching 2026): Richmond and Dougherty Counties

These counties were identified using census-tract level data that showed some of the highest hypertension rates in the state, along with the social and structural conditions that drive those rates. Each county operates its own Heart Health Collaborative — a cross-sector group led by a local Community Champion organization that meets monthly, uses data to guide decisions, and includes residents with lived experience at the table. The Collaboratives come together through the Georgia Heart Health Learning Collaborative to share lessons learned, exchange resources, and strengthen one another’s work.

This site is the shared home of that work. It is designed for Collaborative members, partners, residents, and anyone who wants to understand what community-led cardiovascular health change looks like in Georgia.

The Foundation to a Healthy Heart

At the foundation of any initiative is the “how.”

Before any partners were recruited or a blood pressure screening was delivered, each county started with data. As noted above, a census-tract level Community Health Needs Assessment (CHNA) gave each county a clear picture of who carries the highest cardiovascular burden in their communities, which social drivers are leading it, and what local strengths exist to build upon. The CHNA worked by reviewing county-level statistics and looked closer into specific neighborhoods to identify where hypertension, food insecurity, poverty, and limited access to healthcare coincide.

With that foundation in place, each county was ready to convene its own Heart Health Collaborative and get to work addressing the needs in their communities. The collaboratives use the Plan-Do-Study-Act (PDSA) cycle as their guiding approach. The framework is “Plan” the approach, “Do” the work, “Study” the data, “Act” on what was learned, and repeat. This angle to quality improvement helps the collaboratives treats every event, screening and referral as an opportunity to learn. In practice, no collaborative is exactly the same. Each have their own methodology and approach based on the identified needs in the CHNA and the feedback learned from the ongoing PDSA cycles. This allows each Collaborative to function complimentary to another while still meeting the same goal of improving cardiovascular health in their neighborhoods.

Why Georgia, Why These Counties

The burden of heart disease in Georgia is neither uniform nor inevitable. Statewide data from the OASIS system showed that while Georgia overall faces heart disease rates above national averages, the disease concentrates most heavily in specific counties — and, within those counties, in specific neighborhoods and census tracts. It is there, where the burden is heaviest, that this initiative is focused.

The Georgia Context

Georgia’s cardiovascular disease burden is shaped by a combination of chronic risk factors, uneven access to primary care, and social conditions that make it harder for people to stay healthy. Statewide benchmarks from OASIS, PLACES, and County Health Rankings provide the baseline against which our county burdens stand out:

• • 1 in 3 Georgia adults (33.4%) has been diagnosed with hypertension — the most important modifiable risk factor for heart attack and stroke. (CDC PLACES / BRFSS, 2022–2024)
  • 9% of Georgia adults have high cholesterol, 4.0% have diagnosed coronary heart disease, and 3.3% have had a stroke. (CDC PLACES, 2022–2024)
  • Heart disease is a leading cause of death in Georgia, with an age-adjusted obstructive heart disease mortality rate of 67.9 per 100,000, a stroke mortality rate of 44.0 per 100,000, and a hypertensive heart disease mortality rate of 28.3 per 100,000. (Georgia OASIS, 2020–2024)
  • High blood pressure drives 436.6 ER visits per 100,000 Georgians each year — more than any other cardiovascular cause. (Georgia OASIS, 2020–2024)
  • 1,517 Georgians per primary care physician statewide — a ratio that is much worse in many of our participating counties. (County Health Rankings, 2025)
  • 6% poverty rate, 11.4% uninsured, and 6.3% of households without a vehicle statewide — the social conditions that shape whether good health is possible. (U.S. Census ACS, 2019–2023)

Nationally, Georgia sits within the CDC-recognized “Stroke Belt” — a band of Southeastern states with stroke mortality significantly above the U.S. average (CDC, Division for Heart Disease and Stroke Prevention). Within Georgia, the burden is heaviest in rural southwest Georgia, central Georgia, and pockets of the Atlanta metro where poverty, provider shortages, and food insecurity concentrate. These are many of the same areas that the Collaboratives operate within.

How These Six Counties Were Chosen

In 2023, the CDC awarded cooperative agreements under its Innovative Cardiovascular Health Program (NOA_DP23_0004). All 50 states and the District of Columbia received this funding with a total national investment of up to $275 million over five years. The census-tract level hypertension, stroke, and social vulnerability data helped to identify six counties carrying some of the state’s heaviest cardiovascular burden — and where community-level action could have the greatest effect:

• • Clayton County (Atlanta Metro) — high hypertension burden countywide, with uninsurance reaching 47.7% in the highest-burden census tract, poverty up to 45.3% in tracts around Forest Park and Wexwood, and Hispanic/Latino populations in some tracts four times the state average. (Clayton County CHNA, 2025)
  • Muscogee County (Columbus Area) — a countywide poverty rate of 20.7% (vs. 13.6% state), poverty reaching 52.8% in Urban Core census tracts, and a designated Medically Underserved Area with a primary care Health Professional Shortage Area designation. (Muscogee County CHNA, 2025; HRSA, 2022)
  • Randolph County (Rural Southwest) — life expectancy 4.3 years below the Georgia average (71.3 vs. 75.6 years), a stroke death rate 68% higher than the state (73.7 vs. 44.0 per 100,000), no full-service hospital within 40 miles, and designation as both a Health Professional Shortage Area and Medically Underserved Area. (Randolph County CHNA, 2025; Georgia OASIS, 2020–2024; HRSA, 2022)
  • Macon County (Central Georgia) — ranked 149 out of 159 Georgia counties for health outcomes, a primary care ratio of 12,004:1 (nearly 8x worse than state), no full-service hospital within the county, and a hypertension prevalence of 57.8% in the community of Ideal — nearly double the state average. (Macon County CHNA, 2025; County Health Rankings, 2025; CDC PLACES, 2022–2024)
  • Richmond County (Augusta Area) — launching 2026
  • Dougherty County (Southwest Georgia) — launching 2026

Each county was selected not only for its burden, but also for its strengths: existing community networks, faith-based organizations, local clinical partners, and residents ready to lead. This initiative is built on that existing foundation.

What the Data Says About Priority Populations

Across all four currently active counties, the data points to the same set of priority populations:

• • Black/African American residents — who experience hypertension-related mortality at younger ages and higher rates than the Georgia average. In Macon County, 28.3% of hypertension-related deaths among Black residents occur in adults ages 55–64, compared to 11.3% of such deaths among White residents in the same age group — a signal that heart disease strikes earlier in Black communities. (Georgia OASIS, 2020–2024)
  • Rural residents — in Randolph and Macon Counties in particular, where distance to care, limited primary care capacity, and transportation barriers combine to delay diagnosis and treatment. Randolph County has no full-service hospital within 40 miles; Macon County has no full-service hospital at all. (Randolph and Macon CHNAs, 2025)
  • Low-income households — where poverty, food insecurity, and uninsurance compound cardiovascular risk. In parts of Clayton County, more than half of residents in some census tracts (up to 52.5%) receive SNAP benefits; in Muscogee County, SNAP utilization reaches 66% or higher in Urban Core tracts. (Clayton and Muscogee CHNAs, 2025)
  • Hispanic/Latino communities — particularly in Clayton County around Forest Park, Morrow, and Jonesboro, where Hispanic populations reach up to 63.4% in a single census tract, compared to 10.7% statewide — creating a need for culturally and linguistically tailored outreach. (Clayton County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • Women with hypertension during and after pregnancy — a CDC-designated priority population for this initiative nationally, reflecting the long-term cardiovascular risk associated with hypertensive disorders of pregnancy. (CDC Innovative Cardiovascular Health Program, NOA_DP23_0004)

Each County Collaborative has used its own Community Health Needs Assessment to identify a priority age cohort and priority geographic area within its community — and then designed an action project to meet that population where they are.

What the Data Says About Priority Populations

Across all four currently active counties, the data points to the same set of priority populations:

• • Black/African American residents — who experience hypertension-related mortality at younger ages and higher rates than the Georgia average. In Macon County, 28.3% of hypertension-related deaths among Black residents occur in adults ages 55–64, compared to 11.3% of such deaths among White residents in the same age group — a signal that heart disease strikes earlier in Black communities. (Georgia OASIS, 2020–2024)
  • Rural residents — in Randolph and Macon Counties in particular, where distance to care, limited primary care capacity, and transportation barriers combine to delay diagnosis and treatment. Randolph County has no full-service hospital within 40 miles; Macon County has no full-service hospital at all. (Randolph and Macon CHNAs, 2025)
  • Low-income households — where poverty, food insecurity, and uninsurance compound cardiovascular risk. In parts of Clayton County, more than half of residents in some census tracts (up to 52.5%) receive SNAP benefits; in Muscogee County, SNAP utilization reaches 66% or higher in Urban Core tracts. (Clayton and Muscogee CHNAs, 2025)
  • Hispanic/Latino communities — particularly in Clayton County around Forest Park, Morrow, and Jonesboro, where Hispanic populations reach up to 63.4% in a single census tract, compared to 10.7% statewide — creating a need for culturally and linguistically tailored outreach. (Clayton County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • Women with hypertension during and after pregnancy — a CDC-designated priority population for this initiative nationally, reflecting the long-term cardiovascular risk associated with hypertensive disorders of pregnancy. (CDC Innovative Cardiovascular Health Program, NOA_DP23_0004)

Each County Collaborative has used its own Community Health Needs Assessment to identify a priority age cohort and priority geographic area within its community — and then designed an action project to meet that population where they are.