About Us

The Clayton County Heart Health Workgroup is the cardiovascular health arm of the Clayton County Chronic Disease Collaborative — a cross-sector partnership working to reduce hypertension-related health disparities in Clayton County, Georgia. The Workgroup sits within the broader Chronic Disease Collaborative structure, which allows our heart health work to stay connected to related chronic disease efforts — including diabetes prevention and management and cancer screening — while focusing specifically on the cardiovascular priorities of Clayton County residents.

Clayton County was the first Heart Health Workgroup launched under the Georgia Heart Health Initiative in 2024 and remains the longest-running Workgroup in the state — the first to move through a full cycle of design, soft launch, model enhancement, and relaunch under a Plan-Do-Study-Act (PDSA) quality improvement approach.

Our Workgroup brings together the Clayton County Health District (our Community Champion Lead), Clayton County Fire and Emergency Services (which operates the 4Cs Mobile Medical Unit), Southern Regional Medical Center, community-based and faith-based organizations, food and utilities partners, academic and public education partners, and — most importantly — residents with lived experience in the neighborhoods most affected by cardiovascular disease.

The work is grounded in a census-tract level Community Health Needs Assessment completed in April 2025, shaped by community voice, and continuously refined through the Plan-Do-Study-Act (PDSA) quality improvement cycle. We meet monthly as a full Workgroup.

Community Champion Lead: Clayton County Health District

Home Collaborative: Clayton County Chronic Disease Collaborative

Clayton County Priorities

The Collaborative’s priorities were shaped by the CHNA and direct community input. Three goals guide every Heart Hub event:

• Increase community knowledge and health literacy of hypertension — including healthy eating, physical activity, and stress management.
• Improve access to and management of hypertension — addressing barriers such as transportation, food access, and insurance coverage.
• Strengthen the integration of mental health support — recognizing the impact of stress, anxiety, and depression on blood pressure management.

Priority geographies. Heart Hub events are concentrated in Forest Park, Riverdale, and Jonesboro — where the CHNA identified the highest concentration of heart health risk and the greatest proportion of residents not yet connected to primary care. *(Clayton County CHNA, 2025)*

Priority age cohorts. Adults ages 18–34 and 35–45 are the primary target groups, reflecting a focus on early intervention before cardiovascular risk becomes chronic.

Increase access to primary and preventive care by delivering services in trusted community spaces.

Our Partners

The Heart Hub is a cross-sector effort. The partners below each play a defined role:

Clinical and public health

• Clayton County Health District — Community Champion Lead. Chairs the Collaborative, coordinates public health programming, and provides Healthy Heart Ambassador training and Diabetes Self-Management Education resources.
• Clayton County Fire and Emergency Services — 4Cs Mobile Medical Unit. Operates the Tier 2 mobile medical unit, providing clinical evaluations, lab testing, x-rays, prescription services, and on-site scheduling of follow-up care.
• Southern Regional Medical Center — Pop-Up Clinic. Operates the Tier 1 intake and screening station, provides physician coverage, and leads initial screening and benefits assessment at each event.

Food and nutrition

• WIC (Clayton County) — Provides eligibility screening and enrollment support for families with young children.
• Community food and nutrition partners — Provide fresh produce, fruit and vegetable baskets, and nutrition education at Hub events. Food distribution sites remain part of the Hub rotation.

Corporate and community sponsors

• Corporate sponsors — Participate in Hub events and support participant engagement through raffle items, discount codes, and branded giveaways. Corporate sponsorship outreach was a focus of the January–February 2026 planning cycle.

Recreation and family engagement

• Clayton County Parks and Recreation — Provides on-site activities and games for children, removing childcare as a barrier to participation.

Community voice and outreach

• Resident leaders and persons with lived experience — Central to the Collaborative, co-designing events and materials and providing feedback on workflow and site selection. Walking in Authority Teen Council has been a sustained community voice at the table.
• Healthy Heart Ambassadors — Trained community members who share heart health information and connect neighbors to care through churches, barbershops, and community events.
• American Heart Association — Partner on heart health education and community outreach.
• Atlanta Regional Commission — Regional partner on community health coordination.
• Community-based and faith-based organizations — Support outreach, promotion, and referrals in the priority neighborhoods.

Public education and civic partners

• Clayton County Public Schools — Partner on community health education.
• City of Lovejoy — Civic partner.

Upcoming Events

• Heart Hub Event
  April 25, 2026 | Community Love Day at Lake Spivey
• Heart Hub Event
  May 16, 2026 | Riverdale

Join Us

Heart health is a community effort. The Clayton County Heart Health Collaborative meets monthly and welcomes organizations and residents who want to make a difference in Clayton County.

Ways to get involved:

• Attend a monthly Collaborative meeting
• Volunteer at a Heart Hub event or community screening
• Host a Heart Hub event at your church, apartment complex, workplace, or community space
• Become a Healthy Heart Ambassador
• Refer clients, patients, or neighbors to Heart Hub services
• Partner with the Collaborative to integrate heart health into your existing programs

Interested in joining as a partner organization? Submit a Partner Interest Form and the team will follow up within a week.

References

Data Sources

• Mosaic Group. Clayton County Community Health Needs Assessment. Prepared for the Georgia Department of Public Health Cardiovascular Health Program, April 2025.
• Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP). Online Analytical Statistical Information System (OASIS). Data years 2020–2024. https://oasis.state.ga.us/
• University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2025. https://www.countyhealthrankings.org
• S. Census Bureau. American Community Survey (ACS), 5-Year Estimates, 2019–2023.

About Us

Clayton County was the first Heart Health Collaborative launched under the Georgia Heart Health Initiative in 2024 and remains the longest-running Collaborative in the state — the first to move through a full cycle of design, soft launch, model enhancement, and relaunch under a Plan-Do-Study-Act (PDSA) quality improvement approach.

The Collaborative brings together the Clayton County Health District (the Community Champion Lead), Clayton County Fire and Emergency Services, which operates the 4Cs Mobile Medical Unit, Southern Regional Medical Center, community-based and faith-based organizations, food and utilities partners, academic and public education partners, and the residents with lived experience in neighborhoods most affected by cardiovascular disease. The work is grounded in a census-tract level Community Health Needs Assessment (CHNA) completed in April 2025 and shaped by community voice.

The Collaborative’s flagship program is the Heart Hub — a mobile care model that brings blood pressure screenings, same-day clinical care, social needs support, food access, and family activities directly into the neighborhoods where residents live. This page covers the data and priorities that shaped the Hub, how it works, who makes it run, and what it has achieved since launching in 2025. If you’re looking to attend an event, volunteer, host a Hub activation, or partner with the Collaborative, the Join Us section at the bottom of this page has everything you need.

Community Champion Lead: Clayton County Health District

Home Collaborative: Clayton County Chronic Disease Collaborative

Clayton County Priorities

The Collaborative’s priorities were shaped by the CHNA and direct community input. Three goals guide every Heart Hub event:

• Increase community knowledge and health literacy of hypertension — including healthy eating, physical activity, and stress management.
• Improve access to and management of hypertension — addressing barriers such as transportation, food access, and insurance coverage.
• Strengthen the integration of mental health support — recognizing the impact of stress, anxiety, and depression on blood pressure management.

Priority geographies. Heart Hub events are concentrated in Forest Park, Riverdale, and Jonesboro — where the CHNA identified the highest concentration of heart health risk and the greatest proportion of residents not yet connected to primary care. *(Clayton County CHNA, 2025)*

Priority age cohorts. Adults ages 18–34 and 35–45 are the primary target groups, reflecting a focus on early intervention before cardiovascular risk becomes chronic.

Increase access to primary and preventive care by delivering services in trusted community spaces.

Why This Matters

Clayton County’s CHNA documented a clear pattern: cardiovascular disease is not evenly distributed. In specific census tracts around Forest Park, Morrow, Riverdale, and Jonesboro, the burden of hypertension, heart disease, and related social risk far exceeds both state and county averages. *(Clayton County CHNA, 2025)*

The heaviest-burden neighborhoods

Census tracts around Forest Park, Morrow, Riverdale, and Jonesboro carry the highest burden of hypertension, coronary heart disease, and high cholesterol in Clayton County — and hypertension rates in these neighborhoods exceed the U.S. average. *(Clayton County CHNA, 2025)*

The social conditions that shape the burden

• Uninsurance ranging from 23.9% to 48.0% across priority census tracts — more than 4x the statewide rate of 11.4%. *(Clayton County CHNA, 2025; U.S. Census ACS, 2019–2023)*
• Up to 52.5% of households receiving public assistance (including SNAP) in northern census tracts — significantly higher than the state rate. *(Clayton County CHNA, 2025; U.S. Census ACS, 2019–2023)*
• Poverty up to 45.3% in census tracts around Wexwood and Forest Park — more than 3x the state rate of 13.6%. *(Clayton County CHNA, 2025; U.S. Census ACS, 2019–2023)*
• Unemployment up to 21.4% in northern and central census tracts — roughly 4x the state rate of 5.2%. *(Clayton County CHNA, 2025; U.S. Census ACS, 2019–2023)*
• Median household income as low as $17,273 in some tracts — less than a quarter of the state median of $71,355. *(Clayton County CHNA, 2025; U.S. Census ACS, 2019–2023)*
• More than 50% of residents in multiple census tracts have limited access to food, concentrated around Rex, Allendale Heights, Riverdale, and Irondale. *(Clayton County CHNA, 2025)*

A culturally and linguistically diverse community

Hispanic populations reach up to 63.4% in a single census tract near Forest Park — more than 6x the statewide rate of 10.7% — and foreign-born populations reach up to 44% in tracts around Morrow and Forest Park. These patterns shape outreach strategies and materials. *(Clayton County CHNA, 2025; U.S. Census ACS, 2019–2023)*

The clinical picture

• Resident-to-doctor ratio: 3,906:1 — more than double the state average. *(County Health Rankings, 2025)*
• Hypertension and stroke are leading drivers of emergency department visits, hospital discharges, and mortality in the county. *(Clayton County CHNA, 2025)*
• At the December 2025 Heart Hub launch, 59.5% of participants reported no medical care in the past 12 months — reflecting a significant gap in primary care access the Hub is designed to address.

The Heart Hub

The Heart Hub is Clayton County’s flagship program: a mobile, community-based care model that brings blood pressure screenings, on-the-spot clinical care, social needs support, health education, food, and family activities directly to the neighborhoods most affected by hypertension. The Hub meets residents where they already live, gather, and seek support — at apartment complexes, community events, parks, and partner sites across Forest Park, Riverdale, and Jonesboro.

What makes the Heart Hub distinctive is the way it integrates clinical services into a two-tiered care model, surrounded by a network of community partners who each play a defined role.

The Two-Tiered Care Model

The Hub operates two levels of clinical service, matched to each participant’s level of need:

Tier 1 — Intake, Registration, and Preventive Screening

Operated by Southern Regional Medical Center through its Pop-Up Clinic, Tier 1 is the front door of every Hub event. Every participant moves through Tier 1 first, regardless of why they came. Services include:

• Registration and initial intake
• Blood pressure and glucose screening
• Social Determinants of Health (SDOH) assessment — covering food, housing, utilities, transportation, and more
• Depression screening (e.g., PHQ-9)
• Benefits screening — insurance status, coverage gaps, and navigation to income, food, and housing support

Tier 2 — Same-Day Medical Care via the 4Cs Mobile Medical Unit

Participants whose Tier 1 results indicate a need for more than a screening — elevated blood pressure, abnormal glucose, a positive depression screen, or an unmet need for primary care — are walked directly to Tier 2 care on the 4Cs Mobile Medical Unit, operated by Clayton County Fire and Emergency Services. Residents are not sent home with a referral slip to sort out on their own — they are walked to the next step before they leave. Tier 2 provides same-day, on-site clinical care including:

• Full medical evaluation by a clinician
• Laboratory testing (e.g., A1C and metabolic panels)
• Chest x-rays
• Prescription services and medication refills
• On-site scheduling of follow-up primary care appointments
• Coordinated benefits follow-up with the Tier 1 Benefits Coordinator

What This Means for Participants

A resident who arrives at a Heart Hub event can, in a single visit: get a blood pressure check, have a same-day clinical visit if needed, receive prescription services, complete a social needs screening, get help with insurance and benefits enrollment, pick up fresh food for the week, and leave with a scheduled follow-up appointment — all while their children are engaged in activities nearby.

Every participant also receives a benefits screening on-site. A Benefits Coordinator works with each resident to address insurance status, coverage gaps, and connections to income, food, utilities, and housing support. Residents who screen positive for stress, depression, or other emotional health needs receive a direct connection to behavioral health resources and follow-up coordination before leaving the event.

What Happens at a Heart Hub Event

Every Hub event follows the same core flow, adapted to the site. Here is what to expect when you arrive:

• A greeter welcomes you, explains what’s available, and hands you a registration form.
• Tier 1 (Southern Regional) — blood pressure and glucose screening, a social needs check, and a benefits conversation.
• If your screening shows elevated readings or a need for primary care, you are walked to Tier 2 on the 4Cs Mobile Medical Unit for a full clinical visit.
• Health education station — information on blood pressure, heart-healthy eating, stress management, and managing chronic conditions.
• Fresh produce, fruit and vegetable baskets, and nutrition education through WIC and community food partners.
• Activities and games for children, provided by Clayton County Parks and Recreation — so the whole family can participate.
• Sponsors and community partners may provide giveaways and raffle items to make the event engaging for everyone.

After every event, the core team reviews data and participant feedback. The Collaborative discusses what worked, what to improve, and what changes to make before the next event. This ongoing cycle of improvement is how the Hub has grown from a single screening tent to a fully integrated two-tier care model.

Our Partners

The Heart Hub is a cross-sector effort. The partners below each play a defined role:

Clinical and public health

• Clayton County Health District — Community Champion Lead. Chairs the Collaborative, coordinates public health programming, and provides Healthy Heart Ambassador training and Diabetes Self-Management Education resources.
• Clayton County Fire and Emergency Services — 4Cs Mobile Medical Unit. Operates the Tier 2 mobile medical unit, providing clinical evaluations, lab testing, x-rays, prescription services, and on-site scheduling of follow-up care.
• Southern Regional Medical Center — Pop-Up Clinic. Operates the Tier 1 intake and screening station, provides physician coverage, and leads initial screening and benefits assessment at each event.

Food and nutrition

• WIC (Clayton County) — Provides eligibility screening and enrollment support for families with young children.
• Community food and nutrition partners — Provide fresh produce, fruit and vegetable baskets, and nutrition education at Hub events. Food distribution sites remain part of the Hub rotation.

Corporate and community sponsors

• Corporate sponsors — Participate in Hub events and support participant engagement through raffle items, discount codes, and branded giveaways. Corporate sponsorship outreach was a focus of the January–February 2026 planning cycle.

Recreation and family engagement

• Clayton County Parks and Recreation — Provides on-site activities and games for children, removing childcare as a barrier to participation.

Community voice and outreach

• Resident leaders and persons with lived experience — Central to the Collaborative, co-designing events and materials and providing feedback on workflow and site selection. Walking in Authority Teen Council has been a sustained community voice at the table.
• Healthy Heart Ambassadors — Trained community members who share heart health information and connect neighbors to care through churches, barbershops, and community events.
• American Heart Association — Partner on heart health education and community outreach.
• Atlanta Regional Commission — Regional partner on community health coordination.
• Community-based and faith-based organizations — Support outreach, promotion, and referrals in the priority neighborhoods.

Public education and civic partners

• Clayton County Public Schools — Partner on community health education.
• City of Lovejoy — Civic partner.

Keys to Success — What the Collaborative Has Learned

The Clayton Collaborative has been asked by partners across the Georgia Heart Health Initiative what has made the Heart Hub work. Five themes come up consistently:

1. Clear, defined roles at every event

Every partner has a specific role — greeter, registration, clinical station, children’s activity lead, benefits coordinator, food distributor. When roles are clear and communicated in advance, the workflow runs smoothly and no one leaves without being offered the full range of services.

2. Separate intake from clinical care

Separating Tier 1 (intake, screening, SDOH, benefits) from Tier 2 (clinical care, labs, prescriptions) was the single biggest workflow improvement. It allowed each team to focus, reduced bottlenecks, and dramatically increased the number of residents served at each event.

3. Pair clinical care with the reasons people actually come

Residents come for many reasons — food, curiosity, a neighbor’s recommendation. The Hub works because whatever brings someone to the table, they leave with a blood pressure reading, a social needs check, a benefits conversation, and — if they need it — a clinical visit and a follow-up appointment. The food, children’s activities, and giveaways are not separate from the clinical work; they are what makes the clinical work reachable.

4. Schedule the follow-up before they leave

A warm handoff — walking a resident to the 4Cs Mobile Unit, or scheduling their primary care follow-up on-site — is far more effective than handing someone a phone number and hoping they call. Tier 2 visits include scheduling the next appointment before the resident leaves the event.

5. Treat improvement as an ongoing discipline

Every Hub event is followed by a data review and a structured debrief at the next monthly Collaborative meeting. What worked? What didn’t? What changes will we make next time? This is how the Heart Hub evolved from a single screening tent into an integrated two-tier care program with a full community partnership network.

Our Impact

The Heart Hub has been operating since mid-2025. The data below spans from the program’s soft launch through the enhanced two-tier model, reflecting the Collaborative’s commitment to continuous improvement.

Program-wide (2025 – present)

• 121 community members completed health surveys across Hub events; 80 of 121 (66%) were residents of the priority neighborhoods. *(Clayton County CHNA, 2025)*
• 22 participants received full biometric screenings; 15 of 22 (68%) had elevated or high blood pressure. *(Clayton County CHNA, 2025)*
• 13 of 22 (59%) were connected to primary care; 7 were referred to mental health services; 16 were connected to community services. *(Clayton County CHNA, 2025)*

Enhanced two-tier model launch (since December 2025)

• 37 residents served at a single event at an apartment complex.
• 0% of participants had a history of hypertension, diabetes, or pre-diabetes — confirming the Hub is reaching residents who genuinely need it.
• 5% had not received medical care in the past 12 months.
• 9% were uninsured and received benefits screening and coverage navigation on-site.
• 4% screened positive for hypertension at the event itself.

 

Future measures will track blood pressure improvement, connection to and retention in primary care, emergency department use, and access to community support services. Beginning in July 2026, the Clayton County Health District will sustain Heart Hub activities through the District’s own public health programming.

Upcoming Events

• Heart Hub Event
  April 25, 2026 | Community Love Day at Lake Spivey
• Heart Hub Event
  May 16, 2026 | Riverdale

Join Us

Heart health is a community effort. The Clayton County Heart Health Collaborative meets monthly and welcomes organizations and residents who want to make a difference in Clayton County.

Ways to get involved:

• Attend a monthly Collaborative meeting
• Volunteer at a Heart Hub event or community screening
• Host a Heart Hub event at your church, apartment complex, workplace, or community space
• Become a Healthy Heart Ambassador
• Refer clients, patients, or neighbors to Heart Hub services
• Partner with the Collaborative to integrate heart health into your existing programs

Interested in joining as a partner organization? Submit a Partner Interest Form and the team will follow up within a week.

References

Data Sources

• Mosaic Group. Clayton County Community Health Needs Assessment. Prepared for the Georgia Department of Public Health Cardiovascular Health Program, April 2025.
• Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP). Online Analytical Statistical Information System (OASIS). Data years 2020–2024. https://oasis.state.ga.us/
• University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2025. https://www.countyhealthrankings.org
• S. Census Bureau. American Community Survey (ACS), 5-Year Estimates, 2019–2023.