Macon County Heart Health Collaborative

About Us

Macon County joined the Georgia Heart Health Initiative in 2025 as part of the second cohort — bringing the initiative into a small, rural Central Georgia county made up of four distinct municipalities and carrying one of the highest cardiovascular disease burdens in the state.

The Collaborative brings together Macon County Family Connections (the Community Champion Lead), the West Central Health District, Macon County Public Schools, the Macon County Food Bank, Macon County Parks and Recreation, the Middle Georgia Regional Library, Montezuma Health and Rehab, the Montezuma Police Department, the Oglethorpe City Council, Macon County government, the office of Congressman Sanford Bishop, and residents with lived experience. The work is grounded in a Community Health Needs Assessment (CHNA) completed in December 2025 and shaped by community voice across Marshallville, Ideal, Oglethorpe, and Montezuma. The work is grounded in a Community Health Needs Assessment (CHNA) completed in December 2025 and shaped by community voice across Marshallville, Ideal, Oglethorpe, and Montezuma. (Macon County CHNA, 2025)

The Collaborative’s flagship intervention is Triple Threat: Happy, Healthy Heart — a community event-based model that embeds blood pressure screening, health education, healthy food access, digital health monitor distribution, and linkage to care within existing community gatherings, rather than standing up stand-alone clinical events. This page documents the data and priorities that shaped the intervention, the three-pillar operational model, partner roles, and outcomes reported through April 2026. Organizations interested in joining the Collaborative can find next steps in the Join Us section.

Community Champion Lead: Macon County Family Connections

Home Collaborative: Macon County Heart Health Collaborative

Macon County Priorities

The Collaborative’s priorities were established through the December 2025 CHNA and community input across all four municipalities, confirmed at the January 21, 2026 Collaborative meeting. Three goals guide Triple Threat implementation:

  • Help residents know their numbers — blood pressure, cholesterol, BMI, and other key risk factors — through free on-site screenings delivered at the community gatherings residents already attend.
  • Help residents manage their risk factors — through practical, actionable education on healthy eating, physical activity, stress management, and chronic disease self-management, and paired with digital health monitors.
  • Improve knowledge and use of existing local resources — through a short social needs questionnaire, contact information collection, and warm handoffs to clinics, pharmacies, food pantries, and community programs so that residents can find what is already here.

Priority geographies. Triple Threat is delivered county-wide — across all four municipalities of Marshallville, Ideal, Oglethorpe, and Montezuma — reflecting the small size of Macon County (approximately 11,953 residents) and the Collaborative’s commitment to reach every community rather than concentrate in one. (Macon County CHNA, 2025)

Priority age cohort. Middle-aged adults ages 40–65 — the group with the highest burden of uncontrolled hypertension, obesity, and chronic disease across the county, and the group most likely to be reached at the community events where Triple Threat lives. (Macon County CHNA, 2025)

Why This Matters

Macon County’s CHNA documented a clear pattern: the burden of cardiovascular disease in Macon is among the highest in the state. Macon ranks 149 out of 159 Georgia counties for overall health, with a life expectancy of 71.9 years — nearly four years shorter than the state average of 75.6. (Macon County CHNA, 2025; County Health Rankings, 2025)

Four small municipalities with overlapping burden

Macon County is made up of four distinct municipalities: Marshallville, Ideal, Oglethorpe, and Montezuma. Each carries its own combination of risk. Ideal shows the highest hypertension rate in the county at 57.8% and the lowest preventive checkup rates. Oglethorpe has the highest disability rate at 24% and the highest smoking rate at 30%. Marshallville has the lowest median household income at $24,308. Montezuma has better household stability but still reports uninsurance near 32% — roughly one in three residents. (Macon County CHNA, 2025)

The social conditions that shape the burden

  • Poverty of 33.5% in Marshallville, 39.2% in Ideal, and 32.1% in Oglethorpe — roughly 2.5x the state rate of 13.5%. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • Unemployment of 14.9% in Oglethorpe — nearly 3x the state rate of 5.1% — with rates above the state average in every municipality. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • Median household income of $26,919 countywide — roughly a third of the state median of $74,664. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • SNAP utilization of 27.4% of households countywide, reaching 31.1% in Oglethorpe and 30.6% in Ideal — more than double the state rate of 12.3%. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • Uninsurance of 32.0% in Montezuma — more than 2.5x the state rate of 12.6% — and 18.3% in Oglethorpe. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • No vehicle access in 14.1% of Oglethorpe households and 13.0% of Marshallville households — more than double the state rate of 5.9%. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)

A predominantly Black community with earlier cardiovascular mortality

Macon County is 59.1% Black or African American. Hypertension-related deaths cluster heavily among Black residents, and unlike in many counties, onset begins as early as ages 35–44 — a full two decades earlier than among white residents in the county. This early onset of hypertension-related mortality is a central reason the Collaborative prioritized reaching residents at trusted community gatherings rather than waiting for them to come to a clinic. (Macon County CHNA, 2025; Georgia OASIS, 2020–2024)

The clinical picture

  • Essential (primary) hypertension and hypertensive renal and heart disease is the leading cause of death in Macon County — a different leading cause than the state as a whole. (Macon County CHNA, 2025; Georgia OASIS, 2020–2024)
  • The high blood pressure death rate is 39.4 per 100,000 in Macon — more than three times the state rate of 11.6 — signaling widespread uncontrolled hypertension. (Macon County CHNA, 2025; Georgia OASIS, 2020–2024)
  • Macon is designated both a Health Professional Shortage Area and a Medically Underserved Area, with a primary care provider-to-resident ratio of 12,004:1 — nearly eight times worse than the state ratio of 1,517:1 — and no full-service hospital in the county. (Macon County CHNA, 2025; HRSA, 2022)

Triple Threat: Happy, Healthy Heart

Triple Threat: Happy, Healthy Heart is a community event-based intervention that embeds blood pressure screening, health education, healthy food access, and linkage to care within existing community gatherings — health fairs, memorial walks, church events, sporting events, food drives, and festivals. The model was designed to address the historical difficulty of recruiting residents to stand-alone health fairs in a rural county with a 12,000:1 primary care ratio and no full-service hospital, operationalizing heart health outreach through trusted event hosts rather than new clinical venues.

The intervention’s two defining features are its three-pillar structure — Happy, Healthy, Hearts — and its six-month cohort design, which tracks participants longitudinally across multiple events rather than recording one-time encounters.

The Three Pillars

Each Triple Threat activation operationalizes three connected intervention components, adapted to the host event:

  • Happy — Engagement and motivation. Community engagement activities, and raffles for digital health monitors distributed to participants for BP self-monitoring between events.
  • Healthy — Screening and education. BP and related screenings conducted by the West Central Health District and trained Healthy Heart Ambassadors; structured education on stress management, physical activity, nutrition, and chronic disease self-management; healthy food access through local farms, food drives, and partner food events when available.
  • Hearts — Linkage to care. A five- to six-question Red Form captures participant contact information, social drivers of health, and six-month participation consent. Participants with elevated readings or flagged social needs receive a warm handoff to CareConnect, Chase’s Free Clinic, or the Health Department, with structured post-event follow-up.

What This Means for Participants

Persons that attend a Triple Threat event, can in a single visit: get free blood pressure and health screenings, enter a raffle for a digital health monitor, fill out a short questionnaire that commits you to the six-month cohort, take home healthy food if the host event is paired with a food drive, and — if your numbers are elevated — receive a warm referral to a local provider or program, with follow-up from the Family Connections team in the days after the event.

Participating in Triple Threat also means hearing from the Collaborative between events: a follow-up call or text based on what you shared in your Red Form — whether you’ve connected with a provider, what barriers got in the way, and what the next community gathering is. The whole experience is designed to remove the usual barriers — cost, transportation, time — and to meet you at the places in Macon County you already trust.

What Happens at a Triple Threat Event

Every Triple Threat event follows the same core flow, adapted to the host community gathering. Here is what to expect when you arrive:

  • A Family Connections volunteer greets you at one of two Triple Threat registration tables, placed near high-traffic areas of the host event.
  • You pick up a Triple Threat “passport” and follow a numbered scavenger hunt through each station — screening, education, and the Red Form — where a table representative is ready to assist you.
  • At the screening station, the Phoebe Mobile Wellness Clinic, West Central Health District nurses, or trained Healthy Heart Ambassadors take your blood pressure and explain what the numbers mean.
  • At the education station, you get simple take-home guidance on stress management, physical activity, nutrition, and medication adherence from trusted community messengers.
  • You complete the Red Form — a short five- to six-question survey capturing health history, contact information, zip code, and your six-month Triple Threat participation agreement — then enter a raffle for a digital health monitor.
  • If any of your numbers are elevated or the Red Form flags an unmet need, a volunteer makes a warm handoff to CareConnect, Phoebe Sumter, Dr. Chase’s Free Clinic, Giving Health for telehealth, or the Health Department, and a Family Connections team member follows up in the days after.
  • If you’re bringing children, kid-friendly heart health materials and a dedicated activity area keep them engaged so you can focus on your screening and Red Form conversation.

Every Red Form, BP reading, and educational handout feeds a single auto-calculated dashboard. A Family Connections volunteer makes up to three outreach attempts after each event, and every resource referral gets a five-business-day confirmation text to verify linkage. This Plan-Do-Study-Act (PDSA) workflow is what allowed the Collaborative to validate the model at Heart of Jesse and refine it at Bikers for Bob.

Our Partners

Triple Threat: Happy, Healthy Heart is a cross-sector effort. The partners below each play a defined role:

Community lead and public health

  • Macon County Family Connections — Community Champion Lead. Chairs the Collaborative, plans and staffs Triple Threat registration tables at every event, coordinates volunteer outreach, and leads post-event participant follow-up and data tracking.
  • West Central Health District — Public health lead. Provides Healthy Heart Ambassador training for volunteer partners, supports on-site screenings, coordinates the mobile health unit schedule with Family Connections, and integrates DPH programming into the Triple Threat cohort.

Clinical care and screening partners

  • Phoebe Sumter Medical Center — Regional health system partner. Coordinates the annual Fresh Produce Day / Healthy Food Drive, and serves as a referral destination for residents identified at Triple Threat events.
  • Phoebe Mobile Wellness Clinic — Mobile screening partner. Provides blood pressure and diabetes monitoring at select Triple Threat events where available, supplementing Family Connections-led screening.
  • CareConnect Family Practice (Oglethorpe) — Primary care partner. Accepts direct referrals from Triple Threat events for primary care, screenings, and ongoing chronic disease management.
  • Chase (Free Clinic), Dr. Hatley, and Giving Health — Referral partners supporting residents without insurance or without a regular primary care provider. Giving Health provides telehealth primary care and SDOH support for uninsured and underinsured residents.
  • Healthy Heart Ambassadors — Trained community members, including ambassadors stationed at the Macon County Library and event screeners Ms. Renee and Ms. Gaynette, who deliver screenings and education at Triple Threat events.

Community event hosts and food partners

  • Heart of Jesse Foundation — Host of the February 28, 2026 Triple Threat launch and a long-term partner for family heart health education, with plans for an annual Fun Run / 5K and a Save a Life Contest.
  • Bikers for Bob, Mom Walk, Juneteenth, and the Crossroads Festival — Host community events where Triple Threat activates each season.
  • Howard Brown Farms, Chase’s Farm Market, Kauffman’s Farmarket, and Piggly Wiggly (Montezuma) — Local food and farm partners supporting healthy food access at Triple Threat events and food drives.
  • Unity Community Action, Head Start, and the Family Nutrition Outreach Program (FNOP) — Community service partners extending Triple Threat reach into families with young children.

Civic, education, and faith partners

  • Macon County Schools and the Macon County Library — School partner supporting promotion and back-to-school integration; the library hosts two trained Healthy Heart Ambassadors and serves as a regular mobile wellness screening site.
  • Local faith communities and partner churches — Host Triple Threat events, receive AED provision and training through the Collaborative, and serve as trusted settings for heart health conversations.
  • Residents with lived experience — Central to the Collaborative, providing feedback on event design, messaging, and follow-up protocols.

Keys to Success — What the Collaborative Has Learned

In its first months of implementation, the Macon Collaborative has surfaced clear lessons from embedding a heart health intervention inside existing community gatherings. Five themes have emerged:

1. Go where the community already gathers

In a four-municipality rural county with no full-service hospital and a 12,000:1 primary care ratio, standing up a new clinical event is not the answer. The Collaborative chose instead to partner with the Heart of Jesse Foundation, Bikers for Bob, the Mom Walk, and Juneteenth — gatherings that already draw the community together. This design choice has been validated at every event so far.

2. Design the event as a journey, not a table

A single registration table gets passed by. A scavenger hunt that guides participants through screening, education, and a social needs survey creates an experience — and captures the data the Collaborative needs. At Bikers for Bob the team also learned that table placement matters: a table too far from the main registration flow cost the Collaborative participation it would otherwise have captured.

3. Treat follow-up as where real impact happens

Screening is the moment the community sees; follow-up is where health actually changes. Working through the Heart of Jesse and Bikers for Bob debriefs, the Collaborative built an eight-step follow-up protocol: every completed survey enters a shared spreadsheet, every participant receives an initial text or call within five days of the event with a specific script, a reminder text goes out within 24 hours if there is no response, a phone attempt follows, and then each resource connection — to Dr. Chase’s Free Clinic, CareConnect, Karen Hatten, FNP-C, or Giving Health for telehealth — is documented, followed up on, and confirmed.

4. Build a cohort, not a crowd

The six-month Triple Threat participation agreement signed at every event transforms a one-time contact into an ongoing relationship. The digital health monitor giveaway and the between-event check-ins reinforce that cohort identity — so that residents who show up at Heart of Jesse in February are still engaged at Juneteenth in June.

5. Anchor the work in the organization the community already trusts

Macon County Family Connections already held trust across schools, churches, local farms, and service agencies before the Collaborative launched. Anchoring Triple Threat in Family Connections rather than standing up a new brand let the Collaborative move from first meeting to first community launch in roughly three months.

Our Impact

Triple Threat: Happy, Healthy Heart launched at the Heart of Jesse community event on February 28, 2026. The data below reflects the first months of implementation.

Launch and early events (February – March 2026)

  • Heart of Jesse launch (February 28, 2026): 150–200 expected community participants and 20+ community vendors, with the Phoebe Mobile Wellness Clinic conducting on-site screening. 32 completed Triple Threat surveys collected through the scavenger hunt model; a 33-minute memorial walk, health screenings, and interactive stations for children anchored the event.
  • Bikers for Bob (March 28, 2026): Triple Threat activated at the County Commissioner Chair’s cancer survivor fundraiser with branded materials, magnets featuring the Triple Threat phone number, and a bouncy house engaging children while caregivers completed education. 10 completed surveys and on-site BP screenings, 2 participants flagged with elevated blood pressure, both followed up by phone by the Family Connections team.
  • Kids’ books on heart health (“Circle of Good Habits” and Dr. Seuss’s “Staying Healthy”) distributed at events as part of the family-focused design.

Event pipeline and Collaborative growth

  • 20 partners attended the January 21, 2026 Collaborative meeting where the community-event-embedded strategy was confirmed; 14 at the February 18 planning meeting; 18 at the March 18 Heart of Jesse debrief.
  • Additional Triple Threat activations scheduled at the Phoebe Sumter Healthy Food Drive / Fresh Produce Day (April 24, 2026), the Mom Walk (May 9, 2026), and Juneteenth (June 12, 2026).
  • Two Healthy Heart Ambassadors trained and stationed at the Macon County Library, with additional HHA training underway and AED provision and training for partner churches through the Triple Threat budget.

Future measures will track the number of residents screened for blood pressure, the number showing blood pressure improvement over the six-month cohort period, the number referred to and linked to clinical care, closed-loop social needs referrals, and the upcoming Triple Threat walking team participation. The Collaborative reports data monthly to Mosaic Group and Georgia DPH and reviews it at every monthly Collaborative meeting to refine the next event.

 

Upcoming Events

  • TBD

Join Us

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

Ways to get involved:

  • Attend a monthly Collaborative meeting
  • Volunteer at a Triple Threat event — registration tables, scavenger hunt, or follow-up outreach
  • Host a Triple Threat activation at your church, school, business, community event, or health fair
  • Become a Healthy Heart Ambassador through West Central Health District training
  • Refer neighbors, patients, or congregation members to CareConnect, Phoebe Sumter, or the Health Department for follow-up care
  • 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. Macon County Community Health Needs Assessment. Prepared for the Georgia Department of Public Health Cardiovascular Health Program, December 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.
  • Centers for Disease Control and Prevention. PLACES: Local Data for Better Health. Data years 2022–2024. https://www.cdc.gov/places
  • Health Resources & Services Administration. Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas and Populations (MUA/P), 2022.

About Us

Macon County joined the Georgia Heart Health Initiative in 2025 as part of the second cohort — bringing the initiative into a small, rural Central Georgia county made up of four distinct municipalities and carrying one of the highest cardiovascular disease burdens in the state.

The Collaborative brings together Macon County Family Connections (the Community Champion Lead), the West Central Health District, Macon County Public Schools, the Macon County Food Bank, Macon County Parks and Recreation, the Middle Georgia Regional Library, Montezuma Health and Rehab, the Montezuma Police Department, the Oglethorpe City Council, Macon County government, the office of Congressman Sanford Bishop, and residents with lived experience. The work is grounded in a Community Health Needs Assessment (CHNA) completed in December 2025 and shaped by community voice across Marshallville, Ideal, Oglethorpe, and Montezuma. The work is grounded in a Community Health Needs Assessment (CHNA) completed in December 2025 and shaped by community voice across Marshallville, Ideal, Oglethorpe, and Montezuma. (Macon County CHNA, 2025)

The Collaborative’s flagship intervention is Triple Threat: Happy, Healthy Heart — a community event-based model that embeds blood pressure screening, health education, healthy food access, digital health monitor distribution, and linkage to care within existing community gatherings, rather than standing up stand-alone clinical events. This page documents the data and priorities that shaped the intervention, the three-pillar operational model, partner roles, and outcomes reported through April 2026. Organizations interested in joining the Collaborative can find next steps in the Join Us section.

Community Champion Lead: Macon County Family Connections

Home Collaborative: Macon County Heart Health Collaborative

Macon County Priorities

The Collaborative’s priorities were established through the December 2025 CHNA and community input across all four municipalities, confirmed at the January 21, 2026 Collaborative meeting. Three goals guide Triple Threat implementation:

  • Help residents know their numbers — blood pressure, cholesterol, BMI, and other key risk factors — through free on-site screenings delivered at the community gatherings residents already attend.
  • Help residents manage their risk factors — through practical, actionable education on healthy eating, physical activity, stress management, and chronic disease self-management, and paired with digital health monitors.
  • Improve knowledge and use of existing local resources — through a short social needs questionnaire, contact information collection, and warm handoffs to clinics, pharmacies, food pantries, and community programs so that residents can find what is already here.

Priority geographies. Triple Threat is delivered county-wide — across all four municipalities of Marshallville, Ideal, Oglethorpe, and Montezuma — reflecting the small size of Macon County (approximately 11,953 residents) and the Collaborative’s commitment to reach every community rather than concentrate in one. (Macon County CHNA, 2025)

Priority age cohort. Middle-aged adults ages 40–65 — the group with the highest burden of uncontrolled hypertension, obesity, and chronic disease across the county, and the group most likely to be reached at the community events where Triple Threat lives. (Macon County CHNA, 2025)

Why This Matters

Macon County’s CHNA documented a clear pattern: the burden of cardiovascular disease in Macon is among the highest in the state. Macon ranks 149 out of 159 Georgia counties for overall health, with a life expectancy of 71.9 years — nearly four years shorter than the state average of 75.6. (Macon County CHNA, 2025; County Health Rankings, 2025)

Four small municipalities with overlapping burden

Macon County is made up of four distinct municipalities: Marshallville, Ideal, Oglethorpe, and Montezuma. Each carries its own combination of risk. Ideal shows the highest hypertension rate in the county at 57.8% and the lowest preventive checkup rates. Oglethorpe has the highest disability rate at 24% and the highest smoking rate at 30%. Marshallville has the lowest median household income at $24,308. Montezuma has better household stability but still reports uninsurance near 32% — roughly one in three residents. (Macon County CHNA, 2025)

The social conditions that shape the burden

  • Poverty of 33.5% in Marshallville, 39.2% in Ideal, and 32.1% in Oglethorpe — roughly 2.5x the state rate of 13.5%. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • Unemployment of 14.9% in Oglethorpe — nearly 3x the state rate of 5.1% — with rates above the state average in every municipality. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • Median household income of $26,919 countywide — roughly a third of the state median of $74,664. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • SNAP utilization of 27.4% of households countywide, reaching 31.1% in Oglethorpe and 30.6% in Ideal — more than double the state rate of 12.3%. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • Uninsurance of 32.0% in Montezuma — more than 2.5x the state rate of 12.6% — and 18.3% in Oglethorpe. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)
  • No vehicle access in 14.1% of Oglethorpe households and 13.0% of Marshallville households — more than double the state rate of 5.9%. (Macon County CHNA, 2025; U.S. Census ACS, 2019–2023)

A predominantly Black community with earlier cardiovascular mortality

Macon County is 59.1% Black or African American. Hypertension-related deaths cluster heavily among Black residents, and unlike in many counties, onset begins as early as ages 35–44 — a full two decades earlier than among white residents in the county. This early onset of hypertension-related mortality is a central reason the Collaborative prioritized reaching residents at trusted community gatherings rather than waiting for them to come to a clinic. (Macon County CHNA, 2025; Georgia OASIS, 2020–2024)

The clinical picture

  • Essential (primary) hypertension and hypertensive renal and heart disease is the leading cause of death in Macon County — a different leading cause than the state as a whole. (Macon County CHNA, 2025; Georgia OASIS, 2020–2024)
  • The high blood pressure death rate is 39.4 per 100,000 in Macon — more than three times the state rate of 11.6 — signaling widespread uncontrolled hypertension. (Macon County CHNA, 2025; Georgia OASIS, 2020–2024)
  • Macon is designated both a Health Professional Shortage Area and a Medically Underserved Area, with a primary care provider-to-resident ratio of 12,004:1 — nearly eight times worse than the state ratio of 1,517:1 — and no full-service hospital in the county. (Macon County CHNA, 2025; HRSA, 2022)

Triple Threat: Happy, Healthy Heart

Triple Threat: Happy, Healthy Heart is a community event-based intervention that embeds blood pressure screening, health education, healthy food access, and linkage to care within existing community gatherings — health fairs, memorial walks, church events, sporting events, food drives, and festivals. The model was designed to address the historical difficulty of recruiting residents to stand-alone health fairs in a rural county with a 12,000:1 primary care ratio and no full-service hospital, operationalizing heart health outreach through trusted event hosts rather than new clinical venues.

The intervention’s two defining features are its three-pillar structure — Happy, Healthy, Hearts — and its six-month cohort design, which tracks participants longitudinally across multiple events rather than recording one-time encounters.

The Three Pillars

Each Triple Threat activation operationalizes three connected intervention components, adapted to the host event:

  • Happy — Engagement and motivation. Community engagement activities, and raffles for digital health monitors distributed to participants for BP self-monitoring between events.
  • Healthy — Screening and education. BP and related screenings conducted by the West Central Health District and trained Healthy Heart Ambassadors; structured education on stress management, physical activity, nutrition, and chronic disease self-management; healthy food access through local farms, food drives, and partner food events when available.
  • Hearts — Linkage to care. A five- to six-question Red Form captures participant contact information, social drivers of health, and six-month participation consent. Participants with elevated readings or flagged social needs receive a warm handoff to CareConnect, Chase’s Free Clinic, or the Health Department, with structured post-event follow-up.

What This Means for Participants

Persons that attend a Triple Threat event, can in a single visit: get free blood pressure and health screenings, enter a raffle for a digital health monitor, fill out a short questionnaire that commits you to the six-month cohort, take home healthy food if the host event is paired with a food drive, and — if your numbers are elevated — receive a warm referral to a local provider or program, with follow-up from the Family Connections team in the days after the event.

Participating in Triple Threat also means hearing from the Collaborative between events: a follow-up call or text based on what you shared in your Red Form — whether you’ve connected with a provider, what barriers got in the way, and what the next community gathering is. The whole experience is designed to remove the usual barriers — cost, transportation, time — and to meet you at the places in Macon County you already trust.

What Happens at a Triple Threat Event

Every Triple Threat event follows the same core flow, adapted to the host community gathering. Here is what to expect when you arrive:

  • A Family Connections volunteer greets you at one of two Triple Threat registration tables, placed near high-traffic areas of the host event.
  • You pick up a Triple Threat “passport” and follow a numbered scavenger hunt through each station — screening, education, and the Red Form — where a table representative is ready to assist you.
  • At the screening station, the Phoebe Mobile Wellness Clinic, West Central Health District nurses, or trained Healthy Heart Ambassadors take your blood pressure and explain what the numbers mean.
  • At the education station, you get simple take-home guidance on stress management, physical activity, nutrition, and medication adherence from trusted community messengers.
  • You complete the Red Form — a short five- to six-question survey capturing health history, contact information, zip code, and your six-month Triple Threat participation agreement — then enter a raffle for a digital health monitor.
  • If any of your numbers are elevated or the Red Form flags an unmet need, a volunteer makes a warm handoff to CareConnect, Phoebe Sumter, Dr. Chase’s Free Clinic, Giving Health for telehealth, or the Health Department, and a Family Connections team member follows up in the days after.
  • If you’re bringing children, kid-friendly heart health materials and a dedicated activity area keep them engaged so you can focus on your screening and Red Form conversation.

Every Red Form, BP reading, and educational handout feeds a single auto-calculated dashboard. A Family Connections volunteer makes up to three outreach attempts after each event, and every resource referral gets a five-business-day confirmation text to verify linkage. This Plan-Do-Study-Act (PDSA) workflow is what allowed the Collaborative to validate the model at Heart of Jesse and refine it at Bikers for Bob.

Our Partners

Triple Threat: Happy, Healthy Heart is a cross-sector effort. The partners below each play a defined role:

Community lead and public health

  • Macon County Family Connections — Community Champion Lead. Chairs the Collaborative, plans and staffs Triple Threat registration tables at every event, coordinates volunteer outreach, and leads post-event participant follow-up and data tracking.
  • West Central Health District — Public health lead. Provides Healthy Heart Ambassador training for volunteer partners, supports on-site screenings, coordinates the mobile health unit schedule with Family Connections, and integrates DPH programming into the Triple Threat cohort.

Clinical care and screening partners

  • Phoebe Sumter Medical Center — Regional health system partner. Coordinates the annual Fresh Produce Day / Healthy Food Drive, and serves as a referral destination for residents identified at Triple Threat events.
  • Phoebe Mobile Wellness Clinic — Mobile screening partner. Provides blood pressure and diabetes monitoring at select Triple Threat events where available, supplementing Family Connections-led screening.
  • CareConnect Family Practice (Oglethorpe) — Primary care partner. Accepts direct referrals from Triple Threat events for primary care, screenings, and ongoing chronic disease management.
  • Chase (Free Clinic), Dr. Hatley, and Giving Health — Referral partners supporting residents without insurance or without a regular primary care provider. Giving Health provides telehealth primary care and SDOH support for uninsured and underinsured residents.
  • Healthy Heart Ambassadors — Trained community members, including ambassadors stationed at the Macon County Library and event screeners Ms. Renee and Ms. Gaynette, who deliver screenings and education at Triple Threat events.

Community event hosts and food partners

  • Heart of Jesse Foundation — Host of the February 28, 2026 Triple Threat launch and a long-term partner for family heart health education, with plans for an annual Fun Run / 5K and a Save a Life Contest.
  • Bikers for Bob, Mom Walk, Juneteenth, and the Crossroads Festival — Host community events where Triple Threat activates each season.
  • Howard Brown Farms, Chase’s Farm Market, Kauffman’s Farmarket, and Piggly Wiggly (Montezuma) — Local food and farm partners supporting healthy food access at Triple Threat events and food drives.
  • Unity Community Action, Head Start, and the Family Nutrition Outreach Program (FNOP) — Community service partners extending Triple Threat reach into families with young children.

Civic, education, and faith partners

  • Macon County Schools and the Macon County Library — School partner supporting promotion and back-to-school integration; the library hosts two trained Healthy Heart Ambassadors and serves as a regular mobile wellness screening site.
  • Local faith communities and partner churches — Host Triple Threat events, receive AED provision and training through the Collaborative, and serve as trusted settings for heart health conversations.
  • Residents with lived experience — Central to the Collaborative, providing feedback on event design, messaging, and follow-up protocols.

Keys to Success — What the Collaborative Has Learned

In its first months of implementation, the Macon Collaborative has surfaced clear lessons from embedding a heart health intervention inside existing community gatherings. Five themes have emerged:

1. Go where the community already gathers

In a four-municipality rural county with no full-service hospital and a 12,000:1 primary care ratio, standing up a new clinical event is not the answer. The Collaborative chose instead to partner with the Heart of Jesse Foundation, Bikers for Bob, the Mom Walk, and Juneteenth — gatherings that already draw the community together. This design choice has been validated at every event so far.

2. Design the event as a journey, not a table

A single registration table gets passed by. A scavenger hunt that guides participants through screening, education, and a social needs survey creates an experience — and captures the data the Collaborative needs. At Bikers for Bob the team also learned that table placement matters: a table too far from the main registration flow cost the Collaborative participation it would otherwise have captured.

3. Treat follow-up as where real impact happens

Screening is the moment the community sees; follow-up is where health actually changes. Working through the Heart of Jesse and Bikers for Bob debriefs, the Collaborative built an eight-step follow-up protocol: every completed survey enters a shared spreadsheet, every participant receives an initial text or call within five days of the event with a specific script, a reminder text goes out within 24 hours if there is no response, a phone attempt follows, and then each resource connection — to Dr. Chase’s Free Clinic, CareConnect, Karen Hatten, FNP-C, or Giving Health for telehealth — is documented, followed up on, and confirmed.

4. Build a cohort, not a crowd

The six-month Triple Threat participation agreement signed at every event transforms a one-time contact into an ongoing relationship. The digital health monitor giveaway and the between-event check-ins reinforce that cohort identity — so that residents who show up at Heart of Jesse in February are still engaged at Juneteenth in June.

5. Anchor the work in the organization the community already trusts

Macon County Family Connections already held trust across schools, churches, local farms, and service agencies before the Collaborative launched. Anchoring Triple Threat in Family Connections rather than standing up a new brand let the Collaborative move from first meeting to first community launch in roughly three months.

Our Impact

Triple Threat: Happy, Healthy Heart launched at the Heart of Jesse community event on February 28, 2026. The data below reflects the first months of implementation.

Launch and early events (February – March 2026)

  • Heart of Jesse launch (February 28, 2026): 150–200 expected community participants and 20+ community vendors, with the Phoebe Mobile Wellness Clinic conducting on-site screening. 32 completed Triple Threat surveys collected through the scavenger hunt model; a 33-minute memorial walk, health screenings, and interactive stations for children anchored the event.
  • Bikers for Bob (March 28, 2026): Triple Threat activated at the County Commissioner Chair’s cancer survivor fundraiser with branded materials, magnets featuring the Triple Threat phone number, and a bouncy house engaging children while caregivers completed education. 10 completed surveys and on-site BP screenings, 2 participants flagged with elevated blood pressure, both followed up by phone by the Family Connections team.
  • Kids’ books on heart health (“Circle of Good Habits” and Dr. Seuss’s “Staying Healthy”) distributed at events as part of the family-focused design.

Event pipeline and Collaborative growth

  • 20 partners attended the January 21, 2026 Collaborative meeting where the community-event-embedded strategy was confirmed; 14 at the February 18 planning meeting; 18 at the March 18 Heart of Jesse debrief.
  • Additional Triple Threat activations scheduled at the Phoebe Sumter Healthy Food Drive / Fresh Produce Day (April 24, 2026), the Mom Walk (May 9, 2026), and Juneteenth (June 12, 2026).
  • Two Healthy Heart Ambassadors trained and stationed at the Macon County Library, with additional HHA training underway and AED provision and training for partner churches through the Triple Threat budget.

Future measures will track the number of residents screened for blood pressure, the number showing blood pressure improvement over the six-month cohort period, the number referred to and linked to clinical care, closed-loop social needs referrals, and the upcoming Triple Threat walking team participation. The Collaborative reports data monthly to Mosaic Group and Georgia DPH and reviews it at every monthly Collaborative meeting to refine the next event.

Upcoming Events

  • TBD

Join Us

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

Ways to get involved:

  • Attend a monthly Collaborative meeting
  • Volunteer at a Triple Threat event — registration tables, scavenger hunt, or follow-up outreach
  • Host a Triple Threat activation at your church, school, business, community event, or health fair
  • Become a Healthy Heart Ambassador through West Central Health District training
  • Refer neighbors, patients, or congregation members to CareConnect, Phoebe Sumter, or the Health Department for follow-up care
  • 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. Macon County Community Health Needs Assessment. Prepared for the Georgia Department of Public Health Cardiovascular Health Program, December 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.
  • Centers for Disease Control and Prevention. PLACES: Local Data for Better Health. Data years 2022–2024. https://www.cdc.gov/places
  • Health Resources & Services Administration. Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas and Populations (MUA/P), 2022.