Implementing cardiac risk-factor case management: lessons learned in a county health system

Abstract

Methods: Case-management (CM) can positively influence chronic disease care by facilitating guideline-concordant interventions that improve outcomes through intensive, individualized, longitudinal care. Implementation of CM, however, is difficult. We have identified lessons learned from a cardiovascular risk reduction CM program that may aid future CM implementation.

Introduction: Heart to Heart is both a clinical trial and program dissemination project implementing CM for persons at elevated risk of coronary heart disease (CHD) events in a multiethnic, low-income population in a county health system. Patients were randomized to CM plus usual primary care (N = 212) or primary care alone (N = 207). CM patients received face-to-face nurse and dietitian visits (mean of 14 hours) over 17 months. Visits emphasized behavior change, risk-factor monitoring, and guideline-based pharmacotherapy. A total of 341 patients (81%) were available for follow-up. This CM model is currently transitioning to a County-run program.

Results: Findings demonstrated statistically significant reductions in mean Framingham Risk for CM versus usual primary care (1.56% absolute decrease in 10-year CHD risk, P = 0.007). Favorable changes were noted across most major CHD risk factors. Lessons learned are the need for the following: (1) Strategies for implementing CM in low-income, ethnically-diverse populations, (2) Methods for developing clinically more effective CM, and (3) Approaches to increase the efficiency of cardiovascular CM.

Conclusions: CM for cardiac risk factors faces notable implementation barriers, particularly in County health systems. Specific implementation solutions recommended may help confront these barriers and improve diffusion of this evidence-based and patient centered model of care.

Trial registration: ClinicalTrials.gov NCT00128687.