1. 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.
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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.