Blueprint for Cardiovascular Care Management

A step-by-step guide to develop and implement your strategy

Learn the 13 steps you can take to master CV care management across the continuum—from risk stratifying patients to partnering with high-risk clinics.

When it comes to developing a complex care management strategy, cardiovascular program leaders can’t afford to wait. But since comprehensive care management is still a new competency for many programs, they often don't know how to get started.

This study offers a step-by-step solution. You'll not only learn what a successful care management plan looks like, but how to develop and implement one of your own.

Why now?

Today's CV leaders are more accountable for long-term quality and costs, and they’re facing an increasingly chronic and comorbid patient population. In 2011, an overwhelming 97% of the highest-cost Medicare patients had at least one cardiovascular condition.

This means the traditional focus on reducing 30-day heart failure readmission rates is no longer a sustainable care management strategy. CV leaders will have to broaden their approach to succeed under value-based care.

Read more about the case for comprehensive care management

So what does a comprehensive care management strategy look like?

For one, it's comprehensive in scope, not in scale. Providing complex care management for all patients is practically and financially impossible. Instead, CV programs should focus on the highest-risk patients who are most likely to drive up costs and benefit from more individualized care.

But targeting the right patients is only one part of a successful care management effort. The best plans are:

And with the help of the best practices we've mapped out below, you'll be able to develop and implement a plan that meets these criteria.

13 steps to care management success

Develop a cohesive CV care management strategy

    • Set clear goals that align with institutional objectives
            Related tool: Mission statement template
    • Make a compelling case for institution-wide support
            Related tool:  Ready-to-use presentation
    • Audit existing efforts for duplication, gaps, and efficacy
            Related tool: How-to guide for auditing care management initiatives
            Related tool: Care management program benchmarks
    • Define metrics to track your progress
            Related tool: Metrics picklist
    • Assemble a dedicated CV care management team
            Related tool: Staffing audit
            Related tool: Job descriptions
            Related tool: Staffing benchmarks

Identify your highest-risk patients

    • Risk stratify patients at the point of admission
            Related tool: Risk stratification tool compendium
    • Identify psychosocial barriers
            Related tool: Psychosocial risk factor assessment
            Related tool: Family caregiver assessment
    • Tier resources based on patient risk

Enhance their inpatient care

    • Implement high-risk rounds
            Related tool: Metrics to evaluate round efficiency
    • Create a forum for multidisciplinary collaboration
            Related tool: Complex case conference charter
    • Formalize partnerships for comorbid care

Support their outpatient care

    • Coordinate and streamline post-discharge care plans
    • Bridge the gap between discharge and PCP follow-up
            Related tool: Ambulatory care transition team referral form
    • Partner with high-risk outpatient clinics
            Related tool: High-risk transition clinic referral form and brochure

Benchmark your program

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