title: 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.
  
  
  BACKGROUND
  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.
authors: Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA 94305-5705, USA. kberra@stanford.edu
authors: Kathy
authors: K
authors: Berra
authors: Jun
authors: J
authors: Ma
authors: Linda
authors: L
authors: Klieman
authors: Shauna
authors: S
authors: Hyde
authors: Veronica
authors: V
authors: Monti
authors: Angela
authors: A
authors: Guardado
authors: Silvana
authors: S
authors: Rivera
authors: Randall S
authors: RS
authors: Stafford
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019090:Case Management / Q000458:organization & administration*; D002908:Chronic Disease; D018672:Community Health Planning / Q000458:organization & administration*; D003324:Coronary Artery Disease / Q000208:ethnology / Q000628:therapy*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D011203:Poverty; D015397:Program Evaluation / Q000379:methods*; D018570:Risk Assessment; D012307:Risk Factors; D012309:Risk-Taking