Health Action Sonoma County

Addressing the leading cause of death in the county through resident engagement and sustainable financing.

Sonoma County leaders are coming together in an unprecedented way to build a healthier community for all residents and neighborhoods. Too many people are living under harmful conditions — greater levels of poverty, lack of affordable housing, and limited access to fresh fruits and vegetables. The Portrait of Sonoma County also shows that Santa Rosa is home to some of the largest disparities in the county.

One of the most significant health threats facing Sonoma County residents is cardiovascular disease. Heart disease and stroke are the leading cause of death in Sonoma County. Approximately one-third of County residents (about 149,000 people) suffer from cardiovascular disease.

Reversing these negative health outcomes requires us to confront outdated, conventional wisdom about what makes us healthy. It requires interventions and solutions that go beyond hospital and medical care.

Uniting Sonoma County to Improve Health

Sonoma County Health Action is leading the effort to reduce preventable heart attacks and strokes using the Accountable Communities for Health (ACH) model. Building on a 10-year history of collaboration in this community, Sonoma County leaders are redefining the local health care system by connecting and aligning cardiovascular disease prevention efforts across clinical and community settings. Partners are working together to shift their organizational practices, policies, and programs to achieve the shared ACH goals.


  • Ceres Community Project
  • City of Santa Rosa
  • Community Action Partnership
  • Community Foundation Sonoma County
  • Health Action
  • Integrative Medical Clinic
  • Kaiser Permanente
  • Northern California Center for Well-Being
  • Partnership HealthPlan
  • Petaluma Health Center
  • Redwood Community Health Coalition
  • Redwood Empire Food Bank
  • Santa Rosa Community Health
  • Sonoma County Family YMCA
  • Sonoma County Department of Health Services
  • Sonoma County Human Services Department
  • Sonoma County Regional Parks
  • St. Joseph Health
  • Sutter Health
  • Upstream Investments
  • West County Health Centers

Transforming Sonoma Health Through Partnerships

Through the leadership of Health Action, the ACHmodel is bringing many different sectors together to create a portfolio of interventions to reduce preventable heart attacks and strokes.

Local leaders are prioritizing populations and neighborhoods within Sonoma County that experience the greatest disparities. Community partners are screening and providing coordinated services for these populations. Local health providers are working together to guarantee high-quality care for the prevention and management of cardiovascular disease for all. The ACH also enables residents and organizations to bring their voices to the table and engage in new and deeper ways to improve the health of their communities.


Health Action is specifically designing a portfolio of aligned and mutually-reinforcing interventions to reduce preventable heart attacks and strokes in the greater Santa Rosa area. The portfolio focuses on preventing and managing cardiovascular disease and four key risk factors (high blood pressure, high cholesterol, diabetes, and tobacco use). Specific interventions include:

  • Standardized community blood pressure screenings and linking residents to primary care
  • Preventing Heart Attacks and Strokes Everyday (P.H.A.S.E), evidence-based care for patients with or at-risk for cardiovascular disease
  • Integrating community health workers into clinical care teams to support the prevention and management of cardiovascular disease
  • Mobilizing Sonoma County grocery and convenience stores in low-income neighborhoods to promote and sell healthier foods
  • Smoke-free housing and public education campaigns to fight tobacco use

While collaboration among various agencies is certainly not new, Sonoma County leaders are fundamentally redesigning how community and health care partners work together, and are intentionally co-creating solutions that will enable them to serve residents more effectively. Furthermore, the establishment of the Health Action Wellness fund represents a new and exciting development, as it will weave savings and resources together to invest in strategies focused on prevention and equity. The Wellness Fund is part of a sustainable financing plan to ensure that Health Action has the resources it needs to continue this critical work.

Learn More

To learn more and get involved with Sonoma County Accountable Communities for Health, contact Kristin Fladseth Heidorn at

To learn more about CACHI and the ACH model across California, please contact or visit

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