- Need: Provide cardiovascular disease (CVD) primary prevention services to residents of New Ulm, Minnesota, in an effort to reduce CVD risk factors and heart attacks.
- Intervention: Coaching by telephone to promote lifestyle behavioral changes and preventive medication management via a facility-approved protocol for individuals who were identified as being high risk for CVD.
- Results: Early results indicate this approach is effective at promoting lifestyle changes to decrease the risk of CVD in rural and other underserved areas.
Evidence-levelPromising (About evidence-level criteria)
Heart disease continues to be the chief cause of death for adults in rural America, but primary care services are often underutilized. HeartBeat Connections (HBC) addressed both of these issues for residents of New Ulm, Minnesota. Through a telephone coaching program, HBC supported primary care efforts to reduce heart disease. Patients with heart disease or with the risk of developing heart disease were identified via electronic health record (EHR) data or by referral.
These individuals then received proactive outreach from a health coach over the phone. HBC health coaches, registered nurses, and registered dietitians provided support and education in between clinic visits through these phone appointments every 1 or 2 months with a focus on lifestyle changes. Medical therapies and other community resources were also recommended when appropriate.
HBC is a part of a much larger 10-year initiative called Hearts Beat Back: The Heart of New Ulm Project (HONU) with a goal to reduce the number of heart attacks among New Ulm residents. HONU is funded by Allina Health and is a collaboration of the Minneapolis Heart Institute Foundation, the Center for Healthcare and Research Innovation, the New Ulm Medical Center, and the community of New Ulm.
HBC was active from August 2010 until December of 2014, at which time it ceased due to decreased funding.
This video depicts how the HONU Project reduces heart disease in New Ulm.
HBC offered the following services for participants who opt in to the program:
- Free counseling by phone with a registered nurse or registered dietitian to promote lifestyle behavioral changes including: increasing intake of fruits and vegetables, incorporating healthy fats and fish, increasing whole grains, reducing sodium, limiting added sugars, reducing overall portions and calories, implementing stress management practices and tobacco cessation techniques, and working on weight management. Additionally, some individuals started preventive therapies to further reduce their risk.
- Free heart health education materials: a booklet explaining the individual’s risk status and tips about lifestyle change and a Cooking Healthy for Your Heart booklet with recipes and nutrition information.
- Referral to community resources for weight management, nutrition, physical activity, and tobacco cessation.
- Education and adherence tools for the use of preventative medication for CVD when necessary.
- Goal setting to facilitate lifestyle change.
- Free monthly, follow-up phone visits to promote long-term lifestyle behavior change.
Of the 1,035 patients who were eligible to participate in HBC, 326 (32%) of them enrolled. After 6 months, 83% of enrollees were still engaged in the program. Compared to non-enrollees, early results indicated that HBC enrollees improved their:
- LDL cholesterol – The proportion of participants meeting the program goal of <100md/dL increased by 45% compared to 9% for non-enrollees
- Total cholesterol – participants saw a larger mean decrease in total cholesterol
- Smoking status – half of the participants who started the program and were smokers quit by 6 months
Additionally, there were statistically significant improvements in all lifestyle metrics tracked:
- Consumption of vegetables and fruits
- Physical activity
- Preventative medication use/adherence
- Aspirin use
- Stress level
For more information on program results:
Benson, G., Sidebottom, A., Sillah, A., Boucher, J., Knickelbine, T., VanWormer, J. (2014, March) Primary Cardiovascular Disease Prevention is Leaving the Office: Early Results from the HeartBeat Connections Integrated Telemedicine Program. Poster presented at the American College of Cardiology conference, Washington, D.C.
Benson G., Sidebottom A, VanWormer J., Boucher J., Stephens C, Krikava J. (2013). HeartBeat Connections: A Rural Community of Solution for Cardiovascular Health. Journal of the American Board of Family Medicine, 26:299-310.
Improving Rural Health Takes Effort, Energy, Paula S. Katz.
There were 4 primary barriers for implementing HBC identified by its administrators:
- EHR Documentation Tools: Flowsheets were created within the EHR to track health behaviors such as intake of fruits/vegetables, stress, and physical activity. Even with the addition of these tools, there was still not an efficient way to track outreach attempts so a database was created for HBC that was used in tandem with the EMR system.
- Physician Buy-In: Physicians needed to be convinced of the value and need for this type of service and reassured that it would complement their care, not replace it. Once physician buy-in was secured, enough support was gained to advance the roles of nurses and dietitians so they could initiate preventive medication therapies.
- Convincing People of Their High Risk Status: Most of the people had not been told before that they were considered high risk for heart disease and heard it for the first time from a HBC health coach. Not only were these people skeptical of their status, some people were concerned about the appropriate use of their medical records to identify them for HBC and then the proactive outreach attempt.
- Initial Skepticism from Administrators: The hospital administrators were skeptical about offering a service that was solely phone-based since these kinds of services are typically offered in person, but program acceptance rates alleviated these concerns.
One of the key reasons New Ulm was selected for this project is because its residents are served primarily by a single healthcare facility. This enabled better tracking and identifying of outcomes.
Because each care system has their own unique needs, barriers, and opportunities, these factors should be considered when considering the implementation of a similar health coach program. There are some key points to remember though:
- Engagement of key decision makers
- Early and frequent communication with staff
- Thorough understanding of EHR
- Sustainability of the program
- Measurable outcomes
- Report outcomes frequently
- Share stories
Gretchen Benson from the Minneapolis Heart Institute Foundation is willing to facilitate any questions about the program or replication. Her contact information is below.
Wellness, health promotion, and disease prevention
November 4, 2014
Date updated or reviewed
November 2, 2018
Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.