Patient Engagement as the Rate-Limiting Step: Normalizing Value-Based Care Teams to Address CKM Treatment Gaps

Despite robust evidence, real-world uptake of heart failure guideline-directed medical therapy remains low, even within value-based contracts that have additional dedicated multidisciplinary resources and population health teams.

We evaluated whether layering navigator telephone outreach to patient-portal messaging would increase clinical pharmacist engagement and sodium-glucose cotransporter 2 inhibitor (SGLT2i) initiation among patients with heart failure in an accountable care organization.

Among 1,961 eligible patients with active patient-portal accounts, 1,015 received portal messaging alone, and 946 received portal messaging plus navigator outreach. Navigator outreach increased pharmacist visit completion compared with messaging alone (11.0% vs 7.9%) but did not significantly increase overall SGLT2i initiation (9.6% vs 8.1%). Within the navigator group, 48% of patients were successfully reached by phone. Successful contact was associated with higher pharmacist visit completion and a doubling of SGLT2i initiation compared with unsuccessful contact.

Adding outreach attempts alone was insufficient to meaningfully increase population-level SGLT2i initiation. Successful contact appeared to be the key inflection point, suggesting that care-team connection, not outreach alone, may drive implementation success. True population-level effectiveness requires high rates of programmatic patient engagement to improve engagement with pharmacists who can implement beneficial cardio-kidney-metabolic therapies.