SYSTEM TRANSFORMATION

Project 3.b.i

Evidence-Based Disease Management Strategies – Cardiovascular

WHY WE CHOSE THIS PROJECT

The 2014 MHVC Community Needs Assessment (CNA) found that 29% of members have a cardiovascular diagnosis code on inpatient (IP) admission and 12% have a cardiovascular diagnosis code on an Emergency Department (ED) visit. Notably, cardiovascular disease was the primary cause of death and the second leading cause of premature death. Further, only 65.5% of IP and ED utilizers for cardiovascular diagnoses have had a Primary Care Provider (PCP) visit. These statistics highlight the potential impact for effectively treating cardiovascular conditions on an outpatient basis.

In MHVC, the highest number of beneficiaries with a primary cardiovascular diagnosis on IP or ED visit are in Westchester (49%), Orange (14%) and Rockland counties. Although we will implement this project broadly, we will focus additional resources on these regions as focal “hotspots”; and given a focal age cluster at 50-59, we will also focus efforts on patients in this age group.

We will address this gap by implementing evidence-based guidelines for cardiovascular management and actively engaging patients in outpatient care. The Cardiovascular project aims to improve hypertension control, cholesterol management, and minimize other cardiac risk factors through the implementation of evidence-based best practices via team-based care. Assisting patients in setting and meeting their self-management goals plays an important role in this project. Technology will assist in these efforts as self-management goals, smoking cessation protocols and more will be incorporated into Electronic Health Records (EHRs).

PROJECT GOALS

The main goals of Cardiovascular Project are to:

• Improve Cardiovascular health in our region through implementation of Million Hearts Campaign Strategies
• Integrate evidence-based strategies for cardiovascular disease management into clinical practice
• Aim to improve adherence by providing once-a-day medications when appropriate
• Develop and implement evidence-based clinical treatment protocols for heart disease (high blood pressure, cholesterol, aspirin use)