Intensive Follow-up of high cardiometabolic risk patients. Eight years experience

HERNAN A. PEREZ; LUIS J ARMANDO; NESTOR HORACIO GARCIA

San Francisco

Congreso; AHA COuncil of High Blood Pressure; 2017

AHA

We sought to evaluate the effect of a model of care of people with chronic diseases (MCC) in the control of risk factors (RF) of patient (pts) with high cardiovascular risk (CVD). Thus, we run a Prospective community-based descriptive study of uncontrolled intervention. The latter was an MCC that consisted of: population screening, CV risk stratification with treatment allocation, performance pay, pts award (free medication), inclusion of chronic condition management software (MoviHealth®), educational and self-monitoring tools, weight reduction, chat with health agent and recreational activities. The evaluation period runs from 2008 to 2015 and included >18 years volunteering from a local Helath Insurance. We first determined Framingham Score (FRS) using body mass index (BMI). Those with a FRS 10% were defined as the total area of ​​carotid atherosclerosis for re-stratification risk. Pts with posted FRS> 10% were assisted to manage their CVD, whereas the others were monitored by FD. We established 2 rewarding programs, with one toward the physician in receiving extra payment and the other toward the pts, receiving free medication. Follow-up was supported by MoviHealth®, provision of mobile application for self-monitoring of clinical variables, education activities, use of chat with health worker, ideal weight program, sports and recreational activities. We defined pts with controlled RF when HbA1c