IT helps with care coordination in heart disease prevention program

An intensive population management program that matches heart disease patients to personal nurses and clinical pharmacy specialists is able to save lives, reduce hospital visits and drive down costs, according to a new study from Kaiser Permanente Colorado.

Researchers in the study examined healthcare expenditures in two populations of patients with heart disease: a group of 628 people enrolled in the Kaiser Permanente Collaborative Cardiac Care Service (CCS), a population disease management program, and 628 matched patients receiving standard care. The goal of the study was to determine if an intensive disease management program could provide more value than usual care. Electronic medical records and computerized disease registries helped the clinicians in the study coordinate the care. For example, the electronic tools notify the clinical pharmacist if a patient forgets to pick up a prescription or a cholesterol test shows a change in medication is needed. Using this electronic data, clinical pharmacists can proactively outreach to the patient to support them in making necessary changes. The study found that patients cared for by the CCCS experienced superior health outcomes. As compared to patients receiving usual care, enrollees in the CCCS had better cholesterol control, were more likely to be screened and adhere to important medications like statins, and had far fewer hospitalizations. Overall, CCCS patients had an 89 percent reduction in overall mortality and 88 percent reduction in cardiac mortality compared with patients receiving standard care.