Heart Disease

Lifestyle changes can help you improve your heart health and wellness. Get guidance and support from your health care provider as you make changes. These resources can help you get started on your journey to better health:

• Know your blood pressure numbers. Learn more about healthy and unhealthy blood pressure ranges. Visit the American Heart Association's Understanding Blood Pressure Readings
• Know your cholesterol levels. For more information about what cholesterol is and what your levels mean, visit Control Your Cholesterol and Check. Change. Control. Cholesterol
• Understand your blood glucose (sugar) levels. Uncontrolled blood sugar levels can lead to type 2 diabetes and heart disease. Visit Know Your Numbers - Know Diabetes by Heart to learn more
• Get active and eat nutritious foods to maintain a healthy weight. Find help in our index of public resources supporting physical activity and nutrition
• Don't smoke or get the help you need to quit. Visit the Wisconsin Tobacco Quit Line or call 800-QUIT-NOW (800-784-8669) for free access to coaching and medication to help you quit

When making lifestyle changes, talk to your health care provider for support and guidance.

Managing your blood pressure is important.

Self-management programs offer many benefits. They can help you handle chronic conditions like heart disease. You may also find your quality of life improves. Program participation could even help lower your health care costs.

The Wisconsin Institute for Healthy Aging offers Living Well with Chronic Conditions. This program supports people with high blood pressure, heart disease, asthma, depression, and obesity. Learn more at the Wisconsin Institute for Healthy Aging website.

Self-measurement of blood pressure

Self-measurement of blood pressure is the regular measurement of blood pressure by oneself outside of appointments with a clinical support from your provider, such as care navigator, community health worker, pharmacist, or other care team member. Self-measurement of blood pressure can be done at home or in the community. Monitoring your blood pressure is key to understanding your risks and maintaining a healthy lifestyle. Check with your health care provider, pharmacist, or local health department for locations to check your blood pressure at no cost.

Resources

• Use a validated blood pressure monitor for home use, record measurements using a log, app, or tracker, and then share results with your health care provider.
• The American Heart Association offers blood pressure logs for personal use: My Blood Pressure Log (PDF)

Be an active part in your own care. Before your medical visit, think about health problems to talk about with your provider. Write down your health history. Make a list of your medications. Those items can help you and your provider communicate.

If you don't understand something, ask questions. Bring a family member or trusted friend to your appointments for support and to take notes.

Some health systems offer online health portals that connect to electronic health records. These portals may also allow you to communicate with your providers. You can use it to track your goals, progress, and communicate with your care team.

Follow your doctor's instructions to take your medication to treat high cholesterol, high blood pressure, or diabetes. Always ask questions if you don't understand something.

Request a comprehensive medication review from your pharmacist. They review all the medications you are taking to make sure that they work well together. Have the pharmacist explain how your medications work to maintain your heart health.

Many health systems use electronic health records and health information technology to measure and track clinical quality measures.

Our program promotes the adoption of standardized clinical quality measures to prevent and manage heart disease and related conditions, like high blood pressure and cholesterol.

Additionally, we promote the adoption of these measures to improve monitoring of health and health care disparities among populations and inform activities to eliminate them.

Team-based care

Team-based care (TBC) is a strategy to enhance patient care by having two or more health care providers working collaboratively. It involves a multidisciplinary team collaboratively educating patients, identifying risk factors, prescribing and modifying treatments, and maintaining an ongoing dialogue with patients. Teams may include doctors, nurses, pharmacists, community health workers, and others. Evidence shows that team-based care can lead to significantly improved hypertension control, lowered blood pressure, and improvement medication adherence.

Medication therapy management

Medication therapy management (MTM) is a distinct service to ensure the best therapeutic outcomes for patients. It includes five core elements:

• Medication therapy review
• Personal medication record
• Medication-related action plan
• Intervention or referral
• Documentation and follow-up

MTM has been shown to lower blood pressure, cholesterol, and improve medication adherence. In Wisconsin, MTM is a covered benefit for Medicaid-eligible members. Eligible members receive a comprehensive medical review/assessment (CMR/A). We work closely with the Pharmacy Society of Wisconsin (PSW) and their Wisconsin Pharmacy Quality Collaborative (WPQC) program to engage pharmacists in the promotion of MTM and lifestyle modification. The Pharmacy Society of Wisconsin provides professional training, toolkits, and technical assistance to 250+ accredited pharmacies and nearly 500 certified pharmacists across Wisconsin.

Resources

• Wisconsin Nurses Association created a model of patient-centered team-based care to drive health care transformation that moves toward value-based care, better patient health and safety, and improved population health.
• The Chronic Disease Prevention Program created Team-Based Care Tool for Wisconsin Health Systems and Clinics to help health systems assess their current practices and identify opportunities to improve.
• CDC Million Hearts® Evidence-based Hypertension Treatment Protocols: Simple, evidence-based protocols can have a powerful impact on hypertension control.
• Hypertension Control: Change Package for Clinicians: A quality improvement tool for ambulatory clinics.
• Measure Up Pressure Down™: Provider Toolkit to Improve Hypertension Control: Useful tools, tips, and resources to jump-start hypertension quality improvement initiatives.
• Improving Chronic Conditions, Hypertension & Diabetes: Care & Outcomes: Wisconsin Collaborative for Healthcare Quality (registration required to download)
• MyHEART: Information & Resources for Young Adults with Hypertension: Resource developed by Dr. Heather Johnson from the University of Wisconsin-Madison to address the unmet need of educating young adults on hypertension.

Social Drivers of Health

Social Drivers of Health (SDoH), defined by the CDC (Centers for Disease Control and Prevention) are non-medical factors that affect health outcomes. They include the conditions in which people are born, grow, work, live, and age. SDoH also include the broader forces and systems that shape everyday life conditions.

Screening for SDoH

Screening for SDoHs helps providers understand patients' needs better so they can treat and refer them to appropriate services or supports. As of January 1, 2024, the CMS (Centers for Medicare and Medicaid Services) require healthcare organizations to screen for five SDoH:

• Food insecurity
• interpersonal safety
• housing insecurity
• transportation insecurity
• utilities

Resources

• Social Determinants of Health (SDOH) | About CDC | CDC
• Agency for Healthcare Research and Quality has tools to help healthcare organizations address SDoH.

What is a Community Health Worker?

Community health workers (CHW) are an important part of Wisconsin's public health and health care systems. They are the bridge between you and resources available in your community. CHWs, are the bridge that connect people to care and resources to help them be healthy. CHWs are community members who have lived experience in overcoming barriers to access, navigating systems, and using resources in the communities they serve. The primary goal of a CHW is to improve health outcomes of people in their communities.

CHWs can be found working in many different places like health departments, community organizations, hospitals, clinics, and schools. CHWs work under different job titles, including promotores(as) de salud, community health representatives, doulas, neighborhood navigators, patient navigators, and peer educators, just to name a few.

The Chronic Disease Prevention Program collaborates with partners to advance the sustainability and integration of the CHW workforce to promote equity and positive health outcomes for people in Wisconsin.

Community Health Workers and Heart Health

The Chronic Disease Prevention Program promotes the importance and impacts that CHWs have on improving heart health conditions among community members and families across Wisconsin. The following strategies highlight CHWs and heart health promotion throughout the National and Innovative Cardiovascular Disease funding:

• Ensuring CHWs have equitable and appropriate access to electronic health records and documentation databases
• Integrating CHWs as part of multi-sector care teams
• Working with CHWs to address social service needs and improving community-clinical linkages related to hypertension and cholesterol
• Supporting CHW workforce development through training, professional development, and professional networks
• Supporting CHW workforce sustainability through advancing CHW leadership, authentic CHW allyship, and financial sustainability

Resources

• For additional resources and to learn more about other ways to support CHW work in Wisconsin, visit the Community Health Worker Webpage
• Envision Equity – CHW training and technical assistance center

Self-measured blood pressure (SMBP) monitoring involves an individual's regular use of personal blood pressure monitoring devices to assess and record blood pressure across different points in time outside of a clinical setting. There is strong evidence that SMBP monitoring with clinical support helps people with hypertension lower their blood pressure. Clinical support should occur before, during, and after a health care appointment, and may include instructing clients on how to measure their blood pressure with a home device, helping individuals with medication access and management, leading their own care, and emotional management. Services should consider individuals' perspectives and be tailored to their needs.

Resources

• Along with the American Heart Association, we promote the use of Check. Change. Control., an evidence-based hypertension management program that utilizes self-measured blood pressure monitoring to empower patients in ownership of their cardiovascular health.
• The Chronic Disease Prevention Unit created Self-Measured Blood Pressure Tool for Wisconsin Health Systems and Clinics (P-03163) to help clinics implement a SMBP program for their patients.
• The National Association of Community Health Centers (NACHC) created a Self-Measured Blood Pressure Monitoring (SMBP) Implementation Toolkit to help organizations implement SMBP successfully into their care processes and workflows. The toolkit will help organizations: 1) determine goals and priority populations, 2) align SMBP patient training to their practice environment, 3) consider SMBP tasks by staff roles, 4) review key features and functionalities for choosing a SMBP data management software solution/technology partner, and 5) develop an SMBP implementation protocol.