Implementation of Community-Based Resource Referrals for Cardiovascular Disease Self-Management

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Figure 1.
Practice facilitator training included educating practices about and strategies to support resource inventory completion.
CVD = cardiovascular disease; H3 = Healthy Hearts in the Heartland; PF = practice facilitator.
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Figure 2.
Example generic practice-specific HealtheRx-H3.

Table 1.

Community Resources Indicated for Promotion of the ABCS and for Addressing Comorbidities

	ABCS Recommendations				Addressing Comorbidities
Indicated community resource referrals	A	B	C	S
Blood pressure monitors for sale or use on-site		X
Blood glucose monitors for sale or use on-site					X
Fill prescriptions	X	X	X	X	X
Diabetes education classes		X	X	X	X
Health education classes	X	X	X	X	X
Individual classes or 1-on-1 smoking cessation counseling				X
Individual mental health counseling		X		X	X
Stress management classes		X	X	X	X
Cooking or healthy eating classes		X	X
Weight loss classes		X	X
Group exercise or walking groups		X	X

ABCS = aspirin therapy, blood pressure control, cholesterol management, smoking cessation.

Table 2.

PF-Reported Sociodemographic and Practice Facilitation Characteristics (n = 14)

Sociodemographic characteristics^a
Age, y (median, range)	51 (33-64)
Sex
Women	11/14
Men	2/14
Race
White	11/14
Other	2/14
Education
Bachelor’s degree	4/14
Master’s degree	9/14
H3 practice facilitation characteristics
With whom do you interact at practices that deliver HealtheRx?^b
Physician	12/14
Office or practice manager	10/14
Medical assistant	9/14
With whom do you work most closely on the HealtheRx?^b
Office or practice manager	10/14
Physician	8/14
Nurse or medical assistant	6/14

H3 = Healthy Hearts in the Heartland; PF = practice facilitator.
↵a Responses may not sum to total due to participant refusal or missing data.
↵b Respondents could check all that apply, so responses are not mutually exclusive.

Table 3.

Characteristics of H3 Primary Care Practices Randomized to the POC+PM Arm, Stratified by PF Representation in the Focus Groups (n = 114)^a

	Representation of Practice in PF Focus Groups (n = 81), n (%)	No Representation of Practice in PF Focus Groups (n = 33), n (%)	P Value
Practice size			.58
Solo practice	22 (28)	12 (37)
2-5 clinicians	38 (48)	15 (46)
>6 clinicians	20 (25)	6 (18)
Practice ownership^b			.06
Clinician-Owned solo or group practice	30 (41)	10 (42)
Hospital/health system owned	28 (38)	4 (17)
Federally Qualified Health Center or look-alike	13 (18)	10 (42)
Other or more than 1 type of ownership	3 (4)	0 (0)
Practice specialty			.02
Single specialty	49 (74)	10 (48)
Multi specialty	17 (26)	11 (52)
Practice designated as a MUA or MUP	24 (31)	15 (47)	.11
>100 patient visits per week^c	45 (63)	16 (73)	.38
Staff composition
>3 clinicians (MD, DO, NP, PA)	23 (32)	5 (22)	.37
>3 clinical staff members (RN, LPN, MA, CMA)	31 (43)	12 (55)	.32
>3 office staff members (eg, receptionist)	31 (44)	8 (35)	.42

CMA = certified medical assistant; DO = doctor of osteopathic medicine; H3 = Healthy Hearts in the Heartland; LPN = licensed practical nurse; MA = medical assistant; MD = doctor of medicine; MUA = medically underserved area; MUP = medically underserved population; NP = nurse practitioner; PA = physician assistant; PF = practice facilitator; PM = population management; POC = point of care; RN = registered nurse.
↵a Numbers may not equal 114 due to missing data.
↵b Fisher’s exact test used.
↵c Estimated.