HeartBeat Connections: A Rural Community of Solution for Cardiovascular Health.

BACKGROUND: Cardiovascular disease (CVD) continues to be the leading cause of death among Americans. National guidelines emphasize early identification and control of CVD risk factors, but challenges remain in the primary care setting in terms of engaging patients and improving medical therapy adherence. The rapid growth of electronic health records (EHRs) provides a new way to proactively identify populations of high-risk patients and target them with prevention strategies. The HeartBeat Connections (HBC) program was developed as part of a population-based demonstration project aimed at reducing myocardial infarctions.
METHODS: HBC uses EHR data to identify residents at high CVD risk in a rural community. Participants receive coaching from a registered dietitian or a registered nurse focused on lifestyle behavior changes and preventive medication initiation/titration. DISCUSSION: HBC provides patients with access to nonprescribing professionals on a more frequent basis than typical office visits, and it is focused specifically on helping patients improve lifestyle behaviors and medication adherence as they relate to the primary prevention of CVD.
CONCLUSION: Innovative population health approaches that use EHR data to address common barriers to CVD prevention and engage communities in addressing population health needs are needed to help more patients prevent coronary events.