ASCVD - Atherosclerotic Cardiovascular Disease

• Baylor, Scott & White: 

  • Host “Lunch and Learns” for providers.

    • Educate the providers that ASCVD patients should have an LDL of <70.

    • Educate and encourage primary care providers about the use of high intensity statins for ASCVD patients or determine why they are not on them.

    • Report data to primary care providers showing the percentage of ASCVD patients that are lacking an LDL.

    • Measurement: Run quarterly reports on ASCVD patients that do not have an LDL and the percentage of ASCVD patients that are lacking a high intensity statin and present data to stakeholders.

• Coastal Carolina Health Care: Identified patients not on a statin. Provide standardized education material to patients and encourage use of statins. Identify patients with medication adherence issues and utilize pharmacist as needed. Educated providers on how to overcome statin intolerance and created awareness of the disparity in ASCVD care. Tip: Share transparent provider-level data on a monthly basis. Measurement: Collaborative measure, Percent of ASCVD cohort prescribed high-intensity statin, Baseline 58.0%, Final 58.5%

• Prevea Health: Create standard education for clinical staff. Create standard patient education materials. Brief provider and staff education.

• Privia North Texas: Physician education including individualized reporting to increase statin utilization. Create action plan to address low performers. Create patient level reporting by physician of patients that need statin. Create physician specific reports and metrics quarterly. Measurement: Collaborative measure, Percent of ASCVD cohort prescribed any statin, stratified by race/ethnicity and gender Baseline 78.7%, Final 81%

• PriMED Physicians: Provide documentation of ASCVD risk and patient level goals. Measurement: Organization looked at high intensity statins, LDL goal and any statin usage and compared outcomes for those using Meds Engine vs those who do not.

• Quincy Medical Group: Educating each provider on their patients who have Coronary Artery Disease who are not currently at goal, and creating an individualized plan for each patient with a care manager. Create a partnership between Cardiology and Primary Care through quarterly meetings.

• Southwest Medical Associates: Provider Lunch & Learn to educate about statin prescribing, and LDL test ordering. Provider education including one-pager, and Clinical Decision Support Tool. Tip: Continued socialization of ASCVD education tools beyond Primary Care (OBGYN). Measurement: Collaborative measure, Percent of ASCVD cohort prescribed high-intensity statin with LDL measured and controlled at < 70. Baseline 45.8%, Final 47.9%

Prevea Health: “How to talk to patients about the importance of statin” brief provider and staff education

• Premier Medical Associates: Educate our providers on the importance of utilizing Medisync to ensure best practices in ASCVD care across all populations. Measurement: Quarterly Medisync reports will be run to assess utilization.

• Southwest Medical Associates: Train providers on use of an enhanced point-of-care EHR tool known as CORE that will identify patients with ASCVD who are not on appropriate statins / and not at goal for LDL cholesterol.

Quincy Medical Group: Acquire list of patients diagnosed with ASCVD. Communicate with all providers via e-mail and provider meetings about the importance of specificity and billing for conditions to ensure their problem lists are up to date and reflect patient conditions.

• Coastal Carolina Health Care: Identified patients not on a statin. Provide standardized education material to patients and encourage use of statins. Identify patients with medication adherence issues and utilize pharmacist as needed. Educated providers on how to overcome statin intolerance and created awareness of the disparity in ASCVD care. Tip: Share transparent provider-level data on a monthly basis. Baseline 83.1%, Final 83.2%

• Cooper University Health Care: Developed a Health Maintenance care gap notification in the organizations Electronic Health Record System (EHR), allowing providers to receive notifications when a patient with ASCVD, hypercholesterolemia or Diabetes (MIPS #438) is eligible for a Statin Therapy Medication. If a patient has the appropriate diagnoses, providers will receive a notification. The Health Maintenance Gap will be closed once prescribed a Statin or are Statin exclusion is met. Baseline 70.1%, Final 70.0%

• Hattiesburg Clinic: Action List Utilization. Identified patients with upcoming appointments to prompt discussions with their physicians addressing ASCVD risk reduction. Also focused on patients in need of high-intensity statin therapy without upcoming appointments to schedule shared decision making discussions with their physicians. In addition to utilizing existing quality care teams to assist physicians in identification of at-risk patients, utilized specialty and primary care clinic manager focus groups to identify care coordination barriers and implement best practices.  Baseline 85.2%, Final 86.0% 

• PriMED Physicians: Patient Engagement. Developed patient engagement and education tool that helps patient visual results, treatment goal and strength of recommendation. Tip: Make it easy for providers to have conversations with patients by using a tool that is visual for the patient. Baseline 85.3%, Final 86.4%

• Privia North Texas: High Risk Patient Identification. Include the ASCVD risk score in the banner on the EMR. This allows physicians the ability to see the risk level of each patient while they are in the clinic. Used the indicator to create list of high risk patient's not on statin report. This allowed for smaller, more manageable lists for clinics to work with. Tip: Keep it easy and keep it small. All clinicians are overwhelmed, so make the changes that don’t lead to additional workload for them or their staff. Baseline 78.7%, Final 81.0%

• SIMEDHealth: Pre-visit planning for patients with ASCVD and no statin therapy. Encouraging team based approach in coordinating patient’s care (Reporting, Triage, Tasking, Follow Through). Supporting care pathways for referrals to ASCVD specialists, social services, or dietary counseling. Targeting patients without statin therapy or LDL control. EHR message notifications (“tasks”) sent to provider the day before appointment, prompting engagement and intervention at the point of care. Tip: Send accurate and meaningful information. Baseline 77.4%, Final 82.0%

• Hattiesburg Clinic: Action List Utilization - Identified patients with upcoming appointments to prompt discussions with their physicians addressing ASCVD risk reduction. Focused on patients in need of high-intensity statin therapy without upcoming appointments to schedule shared decision making discussions with their physicians. Utilized specialty and primary care clinic manager focus groups to identify care coordination barriers and implement best practices. Baseline 42.7%, Final 44.6%

• Premier Medical Associates: An advanced clinical decision support tool was used to guide therapy recommendations for ASCVD patients. Baseline 52.4%, Final 64.4%

• PriMED Physicians: Patient Engagement - Developed patient engagement and education tool that helps patient visual results, treatment goal and strength of recommendation at visit. Update treatment plan for each subsequent visit until goal is achieved. Tip: Make it easy for providers to have conversations with patients by using a tool that is visual for the patient. Baseline 51.9%, Final 54.9%

• Baylor, Scott and White: Developed report that generated data for Internal Medicine. Data was shared with the providers to make awareness of the “low hanging fruit” that could be tackled. Tip: Provide validated data to get buy in from providers. LDL control among ASCVD cohort with any statin prescribed.

• Premier Medical Associates: An advanced clinical decision support tool was used to guide therapy recommendations for ASCVD patients. After optimizing dose of high intensity statin or adding additional LDL lowering therapies (ezetimibe/PCSK9 inhibitor/siRNA therapy) re-check LDL level within 30 days so additional therapies may be added if needed. LDL control among ASCVD cohort with any statin prescribed, Baseline 32.6%, Final 30.7%*

• Prevea Health: ASCVD Health Maintenance Topics – LDL and Statin. Creation of Health Maintenance Topic in the EMR to flag patients with ASCVD that are due for an annual LDL measurement and statin prescription is overdue. Tip: Communicating changes amongst the impacted departments is essential in having staff use these topics for patient care. Baseline 36.2%, Final 40.5%

• Quincy Medical Group: Care Manager-Pre-Chart Work-Up. Utilize a Care Manager to preform pre-chart workup the week before on our ASCVD population. Send in-basket message to prescribing provider with most recent LDL, and recommendations for future. Initial focus on Cardiology, have now rolled out to all providers, Cardiology, and Primary Care. Tip: Go all in with all specialties up front. Educate on the recommendations so providers are consistent with their approach. Baseline 29.4%, Final 30.6%

• Coastal Carolina Health Care

  • Targeted enrollment of patients with ASCVD in care management. Measurement: Number of patients with ASCVD enrolled in care management

  • Reviewed discharge notification process. Reviewed notification process for discharges and found there is office variation in follow up visits that are scheduled at the PCP’s office vs those scheduled by Cardiology for ASCVD patients. Patients are prioritized according to their readmission risk score completed during the TOC. Measurement: Collaborative Measures, Percent of ASCVD cohort with LDL measured and controlled at < 70, cohort, LDL control among ASCVD cohort with any statin prescribed, LDL control among ASCVD cohort with high-intensity statin prescribed

  • Evaluate and update existing care pathways with Quality Committee. Ensure all clinicians have access to care pathways using shared drive. Communicate to clinicians and staff, request feedback.

• Hattiesburg Clinic:

  • Action List Utilization - Identified patients with upcoming appointments to prompt discussions with their physicians addressing ASCVD risk reduction. Also focused on patients in need of high-intensity statin therapy without upcoming appointments to schedule shared decision making discussions with their physicians. In addition to utilizing existing quality care teams to assist physicians in identification of at-risk patients, utilized specialty and primary care clinic manager focus groups to identify care coordination barriers and implement best practices. Measurement: Collaborative Measure, Percent of ASCVD cohort prescribed any statin, stratified by race/ethnicity and gender, Baseline  85.2%, Final 86.0%; Collaborative Measure, Percent of ASCVD cohort prescribed high-intensity statin, Baseline 42.7%, Final  44.6%
  • Collaborated with their value-based payers to align medication adherence strategies. Embedded pharmacist to improve statin therapy adherence. 90-day prescription refills (required provider and patient education). Assisted enrollment in health plan mail order pharmacy with automated delivery. Case manage patients with a history of poor statin refill adherence.
• Prevea Health: Create standard work documents for care provided for ASCVD patients. Provide follow up with other services including transitional calls, patient education, and medication compliance. Increase offering of prescription for wellness services.
• Quincy Medical Group: Care Manager-Pre-Chart Work-Up - Utilize a Care Manager to perform pre-chart workup the week before on our ASCVD population. Send in-basket message to prescribing provider with most recent LDL, and recommendations. Initially focused on Cardiology, have now rolled out to all providers, Cardiology, and Primary Care. Tip: Go all in with all specialties up front. Educate on the recommendations so providers are consistent with their approach. Measurement: Collaborative measure, Percent of ASCVD cohort with LDL measured and controlled at < 70, Baseline 29.4%, Final 30.6%
• SIMEDHealth: Focus on patients without statin therapy. Coordinate efforts to inform providers of missing statin therapy. Review patient appointments for the next day and send pre-visit planning task to PCP letting them know statin therapy or adjustments to therapy are needed. This includes 90 day prescription adjustments and lab order requests.
• Southwest Medical Associates: Collaborate with the PreVisit team, contact identified deficient patients, with the aim of scheduling an appointment for the patient with the primary care provider team to discuss treatment options.

• Coastal Carolina Health Care: Model practice identified patients with ASCVD who have not had an LDL in the past 12 months to schedule pre-visit labs, follow-up appointment. Females were identified as disparate patient population. Establish and coordinate dose recommendations and targets between Primary Care and Cardiology. Evaluate and update existing care pathways.

• Ochsner Clinic: Develop a consistent workflow from both Primary Care and Cardiology regarding post event labs and transition to high intensity statin therapy. Building lab and PCSK9i orders into hospital discharge planning. Develop workflow for enrollment into digital medicine programs. Inclusion of lipids into pharmacy post-hospitalization protocol. Provider education.

• Prevea Health: Create standard work documents for care provided for ASCVD patients. Provide follow up with other services including transitional calls, patient education, and medication compliance. Increase offering of prescription for wellness services

• SIMEDHealth:

  • Create a community resources handout/flyer for patients in needed of social services prescription assistance. Utilize FindHelp.org to connect patients to their own local resources. Measurement: Reports built to measure SDOH positive responses and the resources that were handed out. Then cross reference the positive SDOH with the ASCVD patients to identify patients who have ASCVD and SDOH needs to further support those patients through individual outreach.

  • Pre-visit planning for patients with ASCVD and no statin therapy. Encouraging team based approach coordinating patient’s care (Reporting, Triage, Tasking, Follow Through). Supporting care pathways for referrals to ASCVD specialists, social services, or dietary counseling. Targeting patients without Statin therapy or LDL control. EHR message notifications (“tasks”) sent to provider the day before appointment, prompting engagement and intervention at the point of care. Tip: Send accurate and meaningful information. Measurement: Collaborative measure, Percent of ASCVD cohort prescribed any statin, stratified by race/ethnicity and gender, Baseline 77.4%, Final 82.0%

• UC San Diego:

  • Improve Care Pathway by deploying statin prescribing and lipid monitoring health maintenance topics and best practice alerts for primary and secondary prevention of ASCVD to standardize care. Tip: Implement provider education from cardiologist/lipidologist to increase awareness and utilization of pathway.  Measurement: Collaborative measure, Percent of ASCVD cohort prescribed high-intensity statin with LDL measured and controlled at < 70, Baseline 39.4%, Final 46.9%

• Coastal Carolina Health Care: Identified patients not on a statin. Provide standardized education material to patients and encourage use of statins. Identify patients with medication adherence issues and utilize pharmacist as needed. Educated providers on how to overcome statin intolerance and created awareness of the disparity in ASCVD care. Tip: Share transparent provider-level data on a monthly basis. Measurement: Collaborative measure, Percent of ASCVD cohort prescribed high-intensity statin, Baseline 58%, Final 58.5%

• Cooper University Health Care:

  • Evaluate health literacy where possible

  • Provide education appropriate to learning needs to patients with ASCVD prescribed high intensity statin therapy, which could include Information about ASCVD, medication prescribed for ASCVD, heart healthy diet, exercise

  • Refer to Population Health for Longitudinal Care Coordination

  • Goals setting with patients

  • Measurement: Audit referral frequency to population health & evaluate frequency patient education provided to patients during office visit through chart audit.

• Hattiesburg Clinic: Implement standardized provider education through physician face-to-face peer discussions and sharing of collaborative data to raise awareness and prompt provider/patient shared decision making discussions.

• PriMED Physicians: Show the patient the screen/print version of their 2nd risks and treatment recommendations together with “Medical Evidence”. Physicians discuss rationale for treatment and show AHA/ACC “evidence”.

• Quincy Medical Group: Develop consistent and standardized education to provide to patients in Cardiology, Cardiac Rehab, and Primary Offices. Allows patients to understand the importance of a lipid panel, and what their results mean. Medication education, resources for affordability of medications. Small quarterly portal pushes to patients within the cardiac registry with important preventive tips for dietary and lifestyle risks. Marketing team, cardiologists and Primary care providers collaboration to create phrase in EPIC, as well as a handout, that can be given to patients. The portal push will be electronic.

• SIMEDHealth:

  • Review active statin medications who had less than 30 days issued and monitor for 90 day prescription issued.

  • Create social media campaign to promote the importance of statin therapy with ASCVD (monthly posts). Measurement: review past social media posts for opens, clicks, and website hits.

• Southwest Medical Associates: Providing patients with ASCVD-related brochures and rooming with "Protect Your Heart" Poster: why statins are an important part of good health. Tip: Continued socialization of ASCVD education tools beyond Primary Care (OBGYN). Measurement: Collaborative Measure, Percent of ASCVD cohort prescribed high-intensity statin with LDL measured and controlled at < 70, Baseline 45.8%, Final 47.9%

• Cooper University Health Care

  • Evaluate health literacy where possible

  • Provide education appropriate to learning needs to patients with ASCVD prescribed high intensity statin therapy, which could including Information about ASCVD, medication prescribed for ASCVD, heart healthy diet, exercise

  • Refer to Population Health for Longitudinal Care Coordination

  • Goals setting with patients

  • Measurement: Audit referral frequency to population health & evaluate frequency patient education provided to patients during office visit through chart audit.

• Premier Medical Associates: Utilize reports, have Quality team and Pharmacy team begin calls to patients. Tasks to providers to add meds, make med changes and/or medication adherence improvement. Portal education on secondary ASCVD education will be sent when appropriate.

• PriMED Physicians: Developed patient engagement and education tool that helps patient visual results, treatment goal and strength of recommendation. Tip: Make it easy for providers to have conversations with patients by using a tool that is visual for the patient. Measurement: Collaborative measures, Percent of ASCVD cohort prescribed any statin, stratified by race/ethnicity and gender, Baseline 85.3%, Final 86.4%; Percent of ASCVD cohort prescribed high-intensity statin, Baseline 51.9%, Final 54.9%