Cardiovascular disease is among the leading chronic conditions of concern for providers and payers in the U.S., costing $251 billion a year in direct medical costs. In 2035, the number of people with CVD is projected to rise to 131.2 million. While risk increases with age, recent research shows heart disease among younger people is on the rise and more people are dying from CVD, particularly those in rural areas.
By 2050, annual healthcare costs for cardiovascular conditions are projected to reach $1490 billion.
Collaborative care models are transforming cardiovascular health by integrating interdisciplinary care teams to improve access, deliver quality care, and drive engagement.
Here, we explore what a collaborative care model is, and how it can drive better outcomes, boost provider and health plan performance, and provide an optimal member experience. Plus, how organizations can adopt these models to improve cardiovascular care.
What is a Collaborative Care Model?
Collaborative care was first introduced more than 10 years ago by the Center for Healthcare Strategies, as an evidence-based approach for integrating physical and behavioral healthcare that can be implemented within a primary care-based Medicaid health home model and other settings. Since then, the definition of the term has expanded and now can encompass all specialties.
The core principles of collaborative care include:
A patient-centered, multidisciplinary team that works together to provide coordinated, comprehensive healthcare for those with physical and mental health needs.
A population-based care approach in which care teams use a registry and conduct regular caseload consultations to track changes in patients’ symptoms to identify those who aren’t improving and ensure no patient is missed.
Measurement-based care that regularly assesses patients’ symptoms to track changes and adjust treatment, such as repeated screenings to monitor progress over time.
The benefits of collaborative care include:
Improved communication: with a team-based approach, all providers work together—and with the patient and caregivers. Better communication and care coordination closes care gaps and allows for personalized care.
Higher engagement: with whole-person care, patients’ physical and mental health and emotional well-being are addressed, which drives engagement and adherence to care plans.
Lower costs: holistic care helps patients better manage their conditions, prevent complications, reduce ED and hospital admissions, and curb costs.
These models can also reduce healthcare disparities. In fact, a 2024 study funded by the National Institute of Mental Health found that collaborative care intervention significantly reduced PTSD symptoms in Hispanic and non-white populations.
Better Cardiovascular Outcomes
According to a 2024 scientific statement from the American Heart Association, the collaborative care approach can enhance engagement, foster shared decision-making that aligns with the patient’s values and goals, promote more personalized and effective care, and potentially improve outcomes. These models can help patients and their caregivers set goals, and facilitate long-term care planning, transitions of care, and healthcare navigation.
Collaborative care models can vary depending on the care setting, local resources, and the patient’s needs. Among cardiovascular populations for example, the team might consist of primary care providers, cardiologists, nurses, behavioral health providers, nutritionists, social workers, and care coordinators all working together to provide proactive, comprehensive, and coordinated care.
In addition to a multidisciplinary care team, organizations are also adopting digital health technologies such as remote patient monitoring (RPM) and Personal Emergency Response Systems (PERS). These models provide 24/7 monitoring, allow care teams to track and monitor patient vitals, and intervene when necessary.
Digital health technologies have been shown to reduce emergency department utilization and hospital readmissions. A 2020 study by the American Heart Association found that among patients with uncontrolled hypertension, RPM reduced cardiovascular events by 50% over 5 years and reduced costs.
How Healthcare Organizations Can Leverage Collaborative Care Models
As rates of CVD and other chronic conditions rise, more care moves into the home, and value-based care models increase at a steady pace, digital health will continue to be an integral part of collaborative care.
By 2027, RPM is expected to reach $175.2 billion.
Digital health solutions that combine RPM and Personal Emergency Response Systems (PERS) allow collaborative care teams to monitor patient vitals, provide data-driven, timely interventions that lead to better care quality and outcomes, and boost HEDIS (healthcare effectiveness data and information set) scores and STAR ratings.
Some solutions also integrate wellness teams that proactively conduct outreach and HEDIS screenings, coordinate care, close care gaps, and address SDoH (social determinants of health) needs. By building strong relationships and driving engagement, organizations see higher adherence rates, better outcomes, and lower costs.
Partner with Medical Guardian To Improve Cardiovascular Outcomes
At Medical Guardian, we understand the challenges providers face in driving patient engagement and improving outcomes. That’s why we’ve developed a connected suite of solutions—including advanced PERS and RPM devices, caregiver apps, AI-driven tools, and tailored patient engagement strategies—to help close gaps in care and address these needs. By partnering with us, providers can deliver effortless, patient-centered care, stay ahead of industry trends, and create meaningful touchpoints with their patients. Request a demo today to learn more about how we can help transform engagement for your organization.
