Clinic Based and Clinic to Community Partnerships for Evidence-Based Behavior Counseling Interventions in the Primary Care Setting: In Pursuit of Ideal Cardiovascular Health Among Midlife and Older Adults

The American Heart Association’s (AHA) Life’s Simple 7, comprised of seven cardiovascular health metrics, including healthy lifestyle behaviors and ideal metabolic measures, promotes optimal cardiovascular health to reduce cardiovascular disease (CVD) morbidity and mortality. Evidence from population-based studies has demonstrated benefits of ideal cardiovascular health. Healthy lifestyle behaviors are important for primordial, primary, as well as secondary prevention of CVD. Unfortunately, however, is that despite our understanding of the benefits of healthy lifestyle behaviors at any life stage, very few Americans have ideal CVH. Thus, most individuals need to modify multiple lifestyle behaviors, which as was noted in The Premier Trial, is challenging. While small lifestyle changes are possible for many people, achieving ideal CVH requires very significant lifestyle changes. To achieve this, comprehensive (i.e., intensive and multicomponent) evidenced-based behavior change programs are recommended that are guided by the 5A model (assess, advise, agree, assist and arrange) for behavior counseling in primary care settings.

Primary health care providers are the gatekeepers for delivering intensive behavior counseling to their patients. Typically, they focus on the assessing, advising and agreeing components of the 5A model, while patients acknowledge that they need the most help with the assisting and arranging steps, both of which are important for sustained behavior change. This is problematic because the assisting and arranging components are the least addressed steps by health care providers when using the 5A model. Assisting patients in achieving health behavior goals and arranging follow-up support are time intensive and require specialized expertise. In short and episodic clinic visits, it is challenging to provide counseling that requires multiple structured and individualized visits to address each patient’s unique situation to deliver an effective comprehensive behavior change intervention program. This AHA Scientific Statement identifies effective behavioral intervention programs that are feasible for adoption in primary care settings to improve cardiovascular health. A major goal is to guide primary health care provider efforts to offer or refer patients for comprehensive behavioral counseling that is necessary for sustained behavior change. The Scientific Statement provides resources that can be used for implementation of behavioral intervention programs in primary care and community-based settings. The resources offered will help guide health care providers in providing team-based care (e.g., coaches, Registered Dietitians, psychologists, social workers, exercise physiologists) and/or acting as a gateway for connecting patients with clinical-community partnerships that offer multifaceted behavioral intervention programs to promote sustained behavior changes to improve health risk behaviors and CVD risk.

The Scientific Statement presents information about the effectiveness and success of selected behavior counseling intervention programs, delivered in primary care, or referred from primary care settings, to improve cardiovascular risk behaviors and/or risk factors. Some of these programs use team-based care and referral schemes to route patients to appropriate resources that can be based in the primary care setting or community-based settings, of which there are many, such as community centers, places of worship, senior centers, fitness centers, YMCA, among others. This information is intended to encourage clinicians to implement a new practice model for comprehensive behavior change for their patients. The Scientific Statement presents URLs to assist clinicians in identifying community resources for referring patients to counseling and support for lifestyle modification. Cost coverage (including insurance) and reimbursement for behavioral therapy are topics discussed in the Scientific Statement, which also provides information about the Affordable Care Act (ACA) coverage for preventive services.

In addition, the authors discuss the Center for Medicare and Medicaid's Shared Savings Program that provides a financial incentive for the creation of Accountable Care Organizations. This is a resource or a model to develop that assumes financial and medical responsibility for patient care. These programs are intended to foster the creation of a financial model for healthy lifestyle teams that deliver effective behavior change programs.

Because CVD and stroke are the number 1 and 2 causes of death each year, globally, much remains to be done to reduce the burden of CVD. The mission of the AHA is to be a relentless force for a world of longer, healthier lives. Importantly, the AHA is a champion for advancing health equity and removing barriers to health care access and quality. Because of the recent decline in longevity in the United States, especially in under-represented groups, much remains to be done to achieve ideal CVH. The enormous gap between healthy lifestyle behavior recommendations and actions underscores the need to implement comprehensive lifestyle behavior change programs that successfully modify behavior. This will require that the current model of short and episodic clinic visits be revamped for sustained behavior change. The Scientific Statement by Laddu et al. is a great resource for health care providers to use in establishing these programs, both in primary care offices and community practices that serve diverse populations, for CVD prevention and risk factor management. The authors focus on midlife and older adults because of the evidence base for these life stages but these programs could be a model for other age groups across the lifespan. With evidence to support the effectiveness of the behavior change programs presented by Laddu et al., there is good reason to be encouraged that we have a path forward to improve CVH. The lessons learned from this Scientific Statement could inform United States-based clinical practice with the expected outcome being improved CVH.