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Figure
1.
Step
1
Patient
with cardiovascular disease referred to preventive
cardiology program after hospitalization for acute
cardiac event, office visit to cardiologist or other
physician, or following identification by other means
(e.g., via completion of health risk appraisal
by patients enrolled in a managed care plan).
Step
2
Initial
consultation with M.D., R.N., and other program staff
(e.g., dietitian, exercise physiologist).
Risk stratification status is determined,
cardiovascular disease risk management goals are set,
and action plan for achieving these goals is
formulated and initiated.
Focus on lifestyle modification and appropriate
use of medications to optimize risk factors.
Step
3
Lifestyle
modifications are initiated in:
a)
Phase II cardiac rehabilitation program at a cardiovascular disease
risk management facility;
b)
Phase II cardiac rehabilitation program at a satellite facility; or
c)
home-or community-based program (depending on variables including risk
stratification status, place of residence, available
resources, insurance coverage, personal preferences).
Step
4
Long-term
follow-up (lifelong) via mail, telephone contact, and
office visits to evaluate progress in achieving and/or
maintaining cardiovascular disease risk management
goals and to revise action plan as indicated.
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Figure
2
Step
1
Individual
with cardiovascular disease risk factors enrolls in
program. Participant
is either:
a)
self-referred or
b)
referred after hospitalization, physician office visit, or
identification by other means (e.g., completion
of health risk appraisal by individuals enrolled in
managed care plan or worksite health promotion
program).
Step
2
Participant
completes baseline medical history and health habits
questionnaire. Initial
evaluation performed by appropriately qualified
non-physician health care professional.
Computerized date used to generate:
a)
cardiovascular disease risk; management goals;
b)
action plan for achieving goals; and
c)
referrals to participant’s physician for medication changes, to
other health care professionals/programs (e.g.,
psychologist, physician) or for additional laboratory
testing, if clinically indicated.
Step
3
Comprehensive
lifestyle modification program is initiated.
Focus on correct nutrition, physical activity
and exercise training, smoking cessation, stress
management, and weight management.
Use of state-of-the-art behavior modification
techniques, including assessment of stage of readiness
for change and single concept learning theory.
Individualized counseling/guidance by health
care professional.
Step
4
Long-term
follow-up (lifelong) including:
a)
on-going individualized counseling/guidance;
b)
support group meetings;
c)
evaluation of progress in achieving and/or maintaining cardiovascular
disease risk management goals;
d)
d) revision of action plan;
e)
additional physician or other referrals as indicated;
f)
monitoring of compliance with lifestyle interventions and medications;
and
g)
outcomes assessment.
Follow-up
conducted via visits to program, telephone, computer,
and mail using computerized tracking system.
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