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2009 Model Practice Application (Public)
Implementation and Utilization of a Point-of-Care Coronary Heart Disease (CHD) Risk Score in a Large Public Healthcare Setting
Denver Public Health
The program addresses identification of those individuals at-risk for cardiovascular disease, which is important in providing appropriate treatment and avoiding heart disease or stroke.
The goals of our program are the following: to identify individuals seen through our agency who are at risk for cardiovascular disease;to counsel at-risk clients about behavioral and medical therapies to reduce their risk of heart disease. The objectives of our program are the following: to develop an automated version of a point-of-care coronary heart disease (CHD) risk score, which is calculated at the time of the clinical encounter and is displayed on the clinical encounter; to develop a computer link through our computerized electronic medical record, which allows providers to graphically display to the patient their current CHD risk score and allows the provider to be able to demonstrate change in the CHD risk score by modifying clinical and behavioral parameters; using the results from the point-of-care CHD tool, encourage providers to refer at-risk clients (CHD risk score >=10 percent) to our CVD Prevention Program, which uses patient navigators to motivate at-risk individuals to change their behavior by increasing knowledge, influencing attitudes, and challenging their beliefs, and which links clients and their families to available services in their community.
The point-of-care CHD risk score tool was developed duirng a 13 month period (May 2007–May 2008). After testing for accuracy, access to the tool was provided to all clinicians working at Denver Health. The CHD risk score is now displayed on all electronically generated clinical encounters. Through our computerized electronic medical record programs, all providers can chronologically display all CHD scores. CHD risk score information is now a part of the patient’s clinical record. All providers have been trained on the meaning of the CHD risk and use of the clinical tools between June 2008 and August 2008. In addition, for three clinics participating in the DH CVD Prevention Program, providers who identify at-risk individuals (CHD risk score >=10 percent) have been able to refer their patients to the program for enhanced counseling services.
Responsiveness and Innovation
CVD is the leading cause of mortality in Colorado. By racial/ethnic breakdown, the Latino population is at greater risk for CVD compared to non-Latino whites. African-Americans are more likely than whites to have multiple CVD risk factors, to have a higher prevalence of CVD, and to die of CVD. The INTERHEART study demonstrated that 90 percent of the population attributable risk of a first myocardial infarction is due to established modifiable risk factors (smoking, dyslipidemia, hypertension, diabetes, obesity, psychosocial factors, daily consumption of fruits and vegetables, regular alcohol consumption, and regular physical activity). Many individuals in the general population have one or more risk factors for CVD and more than 90 percent of CVD events occur in individuals with at least one risk factor, with few events occurring in individuals with no risk factors, thus supporting the notion of focusing prevention activities on individuals at higher risk for CVD.
Reducing the risk of CVD is part of Colorado’s strategic plan. The state has determined that primary and secondary prevention interventions must be used to target both lifestyle modification (tobacco use, physical inactivity, poor diet, overweight, and obesity) and medical treatment of risk factors (dyslipidemia, high blood pressure (BP), and diabetes) to lower the rate of CVD. The state health department has allocated funds for the development of programs that focus on CVD prevention services. The challenges in providing appropriate care for patients at moderate/high risk of CVD are greatest in disadvantaged populations, particularly those without health insurance, which are disproportionately represented by racial and ethnic minorities. Our institution, DH, is a large, urban, integrated, public safety-net institution that provides medical services for all eligible clients irrespective of insurance coverage. We determined that there were a number of unmet needs in our patient population that needed to be addressed. First, screening for cardiovascular risk factors is often inadequate due to the competing priorities for both the patient and provider in our current system of care. Second, those motivated to incorporate exercise into their lifestyle are often in a home environment not safe for outdoor recreational activities, have financial restraints, or unaware of the resources available to them. Third, many of those targeted do not have adequate information or even motivation on how to choose and prepare healthier foods on a limited income.
The DH CVD Prevention Program’s plan was to implement an aggressive and comprehensive cardiovascular risk assessment and treatment plan in three DH CHS clinics. Our focus has been to identify clients at-risk for CVD (CHD risk score of >=10 percent) and provide risk reduction strategies that complement existing clinical services. After evaluating the outcomes of the program, we plan to expand services to all DH CHS clinics.
To address previously described issues, Denver Public Health (DPH) was awarded a grant to develop the DH CVD Prevention Program. In this program, DPH collaborated with three DH CHS clinics and developed a comprehensive cardiovascular risk assessment and prevention treatment plan using patient navigators who facilitate patient participation in CVD risk reduction activities. As part of the program, a point-of-care system was developed within the medical record for providers to quickly assess CHD risk scores and show the patient their CHD risk and how to modify it. The process involves eligible clients being contacted with those interested meeting with navigator who completes a baseline risk assessment and discusses potential CVD risk reduction activities (e.g., use of self-management tools, nutrition education, community-based exercise programs, and referrals to Colorado QuitLine) and facilitates the client’s transition to the available community-based programs. We determined that patients were more likely to p
Agency Community Roles
DPH is the local public health department for the City and County of Denver. Its focus is to improve the health of the residents of Denver. As such, DPH provides contracted public health services for the City, which includes recommendations for addressing disease control, provision of direct disease control services (e.g., tuberculosis, HIV, STD clinics, and immunizations), administration of vital records/vital statistics (such as births and deaths), tobacco control, STD/HIV training programs, and health promotion/wellness programs. Our health promotion and wellness programs at DPH are community-based and encompass a number of important areas of health concerns. These include tobacco control, preconception health, immunization outreach activities, STD/HIV/TB prevention activities, worksite wellness, LiveWell West Denver (community-based health promotion program), CVD prevention activities, and the West Denver CAREs project, which addresses public health and environmental concerns on the west side of Denver. All of our programs focus on underserved and low-income communities. Through the DPH health promotion department, the DH CVD Prevention program has been conducted. Using the foundations created through our other health promotion activities, we were able to develop a CVD prevention program for clients seen in our clinics that are community focused enhancing the services offered in the clinic.
Our partners for this program have included the Denver Parks and Recreation Department of the City and County of Denver, which offers access to recreation services for our clients; the CSU Cooperative Extension, which has offered culturally appropriate hands-on nutrition classes; the Colorado Quitline, which provides individualized smoking cessation services; and the LiveWell Denver communities, which offers community-based activities in the areas used by our clients.
Using our position as a local public health department, we work with community-based organizations, the City and County of Denver Departments of Public Works, Environmental Health, and the Denver Parks and Recreation program to contribute to the agenda for addressing policies that will promote beneficial health behaviors in the community. We currently have connections to several government/community-based organizations that focus on improving access to and programs for underserved communities and we will use these relationships to effect policies to improve health behaviors. We are involved in developing a coordinated linkage for all Denver LiveWell initiatives that would be more streamlined, integrated, and improve the establishment of policies affecting these communities. We also work with Denver Greenprint and Living Streets initiatives to promote safe and healthy environments for Denver communities. Finally, in collaboration with Denver Environmental Health, DPH recently released a health profile of the City and County of Denver that assesses the current health status of the City and County of Denver. This information has been directed to the Mayor, the City Council, and other health advocates to address the social, economic, and environmental factors that influence health in addition to improving health access. All of these areas have policy implications for our DH CVD program.
As part of the Denver Health (DH) CVD Prevention Program, we used funds to develop an automated version of a point-of-care CHD risk score with the DH Information Services (IS) department. The point-of-care CHD risk score is calculated at the time of the clinic visit and documented on the clinical encounter with other clinical information. In addition to CHD risk score being displayed on the clinical encounter, we developed a computer link that allows providers to graphically display to the patient their current CHD risk score using pre-populated information. This tool then allows providers to visually demonstrate to the patient how their current risk could change through behavioral changes (e.g., smoking cessation, dietary modifications) and medical therapy (e.g., lipid reduction, treatment of hypertension). DH is a large, urban, integrated, public safety-net institution that has invested significant capital in the development of an integrated system-wide electronic information system. This comprehensive and integrated clinical information system has been recognized nationally and is unique among minority-serving systems. This system has been used to develop registries of patients with chronic diseases for research and clinical purposes. As part of the DH CVD Prevention Program we obtained $30,000 to develop the point-of-care CHD risk score tool. Using these funds, an interdisciplinary team consisting of information technology personnel, clinicians with expertise in CVD, and our CVD Prevention team was formed to develop and implement this tool. Development of this computerized tool was incorporated into several other clinical applications, including the diabetes registry and the hypertension registry, thus providing additional support for the tool’s development.
Early identification of CVD risk is important to reach those who need appropriate treatment. In this regard, the National Cholesterol Education Program guidelines recommend using the Framingham Risk Score (FRS) (note: the Framingham Risk Score will be referred to as the CHD risk score) as the basis to identify patients with an increased 10-year risk for CVD events. At DH, there are a significant number of patients at risk for CVD, with most clients being racial/ethnic minorities. Addressing those at risk for CVD is important to avoid the development of heart disease or stroke. However, at the time of a clinical encounter, it is a challenge for the provider to manually calculate the CHD risk score, limiting use of the score by the primary care provider. Thus the need to develop a tool that calculates a current CHD score for the provider at the time of the clinical visit that is easily accessed by the clinician. At DH, patients are seen by their providers infrequently; visits have a number of competing demands, which frequently affects the ability of the provider to address CVD risk behaviors. Providers need assistance in helping their clients address behaviors that lead to heart disease. As such we developed the DH CVD Prevention Program, which involves patient navigators who assist patients in client-centered approaches for avoiding heart disease and assists in accessing community-based services. As part of our program, we used funds to develop an automated version of a point-of-care CHD risk score. The specifications needed to build this computer application were determined, with the score becoming part of the already established electronic medical record system being used. These specifications included having the point-of-care CHD risk score calculated at the time of the clinic visit and documented on the clinical encounter with other clinical information. The process for calculating the CHD risk score was based on previously established eligibility requirements (e.g., age requirements, no prior CVD history, etc). At DH, all clinical information is electronically available through multiple computerized sources including the Lifetime Clinical Record (LCR), electronic
The agency has felt that the development of the CHD risk score tool has been very worthwhile. The original grant provided resources to develop the point-of-care tool, but did not have any funds for maintenance of the software. Denver Health has committed resources to ensure that the tool is maintained.
Using the intervention described as the foundation, we plan to expand our services by providing the CVD Prevention intervention for all eligible and interested clients seen through the DH Community Health Services clinics. In January 2009, we submitted another proposal to the same state funder (CCPD). For this program, we are taking the lessons learned from our original DH CVD Prevention Program to expand the navigational services offered by providing services to 1,600 eligible clients (i.e., CHD risk score of >=10 percent) who are seen at any of the eight DH Community Health Services clinics. These clinics provide clinical services annually to approximately 26,000 patients between the ages of 30–74 years who would be eligible for screening with the CHD risk score, of which more than half are Latino and 20 percent are African-American. Clients will be referred to the patient navigators by the providers who identify an at-risk person using the automated CHD Risk Score too. Then, using patient navigators to provide one-on-one counseling on CVD risk reduction, clients will set goals for reducing their risk of CVD. As part of this program, we will connect at-risk clients to community-based activities throughout the City and County of Denver and will collaborate with our community-based partners to enhance needed services. Furthermore, we will develop an educational component that will provide training for our DH medical providers and our community-based partners on brief counseling techniques using behavioral theories to enhance the clinical and programmatic services provided. To assess the effect of this program, we will monitor patient outcomes (i.e., behavioral and clinical) and conduct a cost-effectiveness evaluation to determine if developing this type of program offers benefit for the cost of providing the services described and to assess the potential sustainability of the program. Finally, using our position as a local public health department, we will work to develop and advocate for policies and programs that increase beneficial health behaviors in the City and County of Denver. As for the CHD risk score tool, the computerized system is now an established part of the electronic medical record and clinical utilities of the agency. The Informational Services department of the hospital supports the application. The CHD risk score information is automatically downloaded into our agency’s data warehouse and is used for other medical registries (DM registry, HTN registry). Finally, as part of the grant application submitted in January 2009, we have requested additional funds to refine the CHD risk score tool to more accurately measure CVD risk (i.e., using systolic blood pressure treated or untreated). This clinical application requires additional programing to link pharmacy records to the CHD risk score information.
Outcome Process Evaluation
Developing the point-of-care CHD risk score is more time intensive that anticipated because it was necessary to carefuly determine the specifications needed to calculate the tool. Additionally, some of the data entry systems in place did not interface well with the program and needed modifications to allow the CHD score to accurately be calculated.
Although approximately 1,000 patients have had the tool used in their medical care, only 12 percent of active users with CHD risk scores >=10 percent had the tool demonstrated to them. Further education on the importance of the tool and its use is needed.
Information not provided in 2009