HEART ATTACK & STROKE FREE ZONE PROJECT Preventing cardiovascular disease through health coaching The project described was supported by Grant Number 1C1CMS331345 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor. www.betheresandiego.org Project Successes Outcomes Lessons Learned Patient Story TEAMWORK YIELDS BIG RESULTS STRUCTURE BUILT TO SUSTAIN PROGRESS Team Approach 0% 20% 40% 60% 80% 100% Quarter Quarter 4 Quarter 5 Quarter 6 Quarter 7 Quarter 8 PERCENT OF PATIENTS ADHERENT TO THIAZIDE-ACE/ARB Our medical director serves as a physician champion, sharing information about our program with all providers in our network. Care specialists reach out to potential patients over the phone, inviting them to participate in the program. Case managers (RNs) serve as the health coaches, educating patients on medication adherence and healthy lifestyle choices. When the patient enrolled in the program in August 2015 he had high blood pressure and cholesterol readings. He told the health coach he was eating out often. He was limiting the table salt at home but hadn’t considered the sodium content of the food he ate at restaurants, which he learned could be high. He created a spreadsheet of low-sodium options at his favorite eateries. He is excited about his progress - a recent blood pressure reading was 112/80 - and is now focusing on his cholesterol. He said that the regular health coaching calls have helped to keep his momentum going. COACHING IDENTIFIES HIDDEN CULPRIT • We have been able to successfully enroll more than 1,200 patients into this program. • Patients are very appreciative of phone appointments and home visits. These allow for personalized educational moments, involving real-time assessment of diet and exercise. • Across the organization, there has been additional reinforcement of best practices for hypertension management. • We built an Access database to help track our entire population. • We created documents to help to ensure the consistency of patient care for the health coaches. • Our team cross-monitors charts and conducts chart audits on a consistent basis to prevent any drift from best practices.

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HEART ATTACK & STROKE FREE ZONE PROJECTPreventing cardiovascular disease through health coaching

The project described was supported by Grant Number 1C1CMS331345 from the U.S. Department of Health and Human Services,

Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do

not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The

research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by

the findings of the independent evaluation contractor.

www.betheresandiego.org

Project Successes

Outcomes

Lessons Learned

Patient Story

TEAMWORK YIELDS BIG RESULTS STRUCTURE BUILT TO SUSTAIN PROGRESS

Team Approach

20%

40%

60%

80%

100%

Quarter Quarter 4 Quarter 5 Quarter 6 Quarter 7 Quarter 8

PERCENT OF PATIENTS ADHERENT TO THIAZIDE-ACE/ARB

Our medical director serves as a physician champion, sharing information about our program with all providers in our

network. Care specialists reach out to potential patients over the phone, inviting them to participate in the program.

Case managers (RNs) serve as the health coaches, educating patients on medication adherence and healthy lifestyle choices.

When the patient enrolled in the program in August 2015 he had high blood pressure and cholesterol readings. He told the health coach he was eating out often. He was limiting the table salt at home but hadn’t considered the sodium content of the food he ate at restaurants, which he learned could be high. He created a spreadsheet of low-sodium options at his favorite eateries. He is excited about his progress - a recent blood pressure reading was 112/80 - and is now focusing on his cholesterol. He said that the regular health coaching calls have helped to keep his momentum going.

COACHING IDENTIFIES

HIDDEN CULPRIT

• We have been able to successfully enroll more than 1,200 patients into this program.

• Patients are very appreciative of phone appointments and home visits. These allow for personalized educational moments, involving real-time assessment of diet and exercise.

• Across the organization, there has been additional reinforcement of best practices for hypertension management.

• We built an Access database to help track our entire population.

• We created documents to help to ensure the consistency of patient care for the health coaches.

• Our team cross-monitors charts and conducts chart audits on a consistent basis to prevent any drift from best practices.