Administrative activities | • 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. |
Patient-contact activities | • 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 [15]. • 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. |