• Access EMR and collect medical record data to evaluate gaps in therapy for the patient.|
• Document all patient and provider encounters and time (minutes) used for each activity to determine appropriate billing.
• Provide composite tracking and progress reports for all subjects treated by a given physician.
• Completed necessary prior authorizations for medication insurance coverage.
• Email, phone, and/or text message the patient every 1–2 weeks × 2 months then monthly to engage patient with self-monitoring.|
• Use motivational interviewing to conduct monthly follow-up assessment and counseling for medication adherence, side effects, exercise, coronary heart disease (CHD) knowledge, weight management, diet, tobacco use, alcohol use, and associated disease state education.
• Assess stages of change for key issues such as exercise, diet, weight management, and tobacco use .
• Provide frequent contact with patient to improve preventive health screening. Develop an action plan that addresses gaps in preventive health screening or guideline-concordant therapy, update medication list, and send recommendations for medication changes.