ABCS refers to a series of interventions that can reduce the risk of illness and death due to cardiovascular disease, diabetes, and their risk factors: aspirin use, controlling blood-pressure and cholesterol, and stopping smoking.
The PCC, the Montgomery County Department of Health and Human Services, and a variety of community-based organizations, hospitals, and independent clinics are working together to increase screening and awareness of high blood pressure, diabetes, high cholesterol, tobacco use and risk factors for heart disease and stroke.
Montgomery County has a burden of illness, death, and disability directly attributable to cardiovascular disease and its risk factors. High cholesterol, high blood pressure, smoking, and being overweight or obese are on the rise within the county’s minority and low-income population. According to Healthy Montgomery, deaths from heart disease and stroke in Montgomery County are highest among African American men. Diabetes ranks as the fourth leading cause of death among African Americans, fifth leading cause of death among Hispanics/Latinos, and sixth leading cause of death among Asians and Pacific Islanders.
The ABCS pilot program tests strategies to improve patient outcomes in a variety of ways, from raising awareness and public education efforts at health fairs and other community events, to implementing proven ABCS strategies at primary care encounters for patients in the target population, and ramping up referral efforts to ensure that at risk patients are connected to a regular source of primary care. Specific strategies include:
Culturally and linguistically appropriate outreach about cardiovascular risk factors through health fairs and public events.
Patient navigation by peer health promoters and community health workers who channel individuals who have cardiovascular risk factors but no usual source of primary care to a participating clinic and work to increase attendance at appointments.
Training primary care providers in the six participating clinic sites on the most current evidence-based guidelines for treating specific patient populations and sub-populations.
Providing Continuing Medical Education credits on issues pertaining to diabetes, hypertension and cholesterol management.
By September, 2013, each clinic participating in the pilot program will have integrated known ABCS interventions into usual clinical care, and will perform at 90% of HEDIS Medicaid benchmarks for clinical measures relevant to ABCS interventions.