An implementation trial of a telephone-based care management program for patients following myocardial infarction.

The intervention consists of a telephone-based care management program delivered over a period of 6 months during which the participant will receive 10 x 20 minute telephone coaching sessions. Participants will receive an interactive workbook and educational resource. In addition to the initial telephone call, the care manager will call the participant 9 more times during weeks 2, 4, 6, 8, 10, 12, 16, 20 and 24 (final call). Following the initial call, the remaining calls will be structured as follows: 1) introduction & identification of any new symptoms or change in symptoms, i.e., identification of any new alerts; 2) follow-up on progress towards previous lifestyle/clinical goals and targets; 3) assess and counsel on relevant behavioural, psychological and social and clinical risk factors, as well as, to encourage treatment/medication compliance; 4) review session, summarise next tasks/actions, patient to record these in their Workbook and agree on time for next phone call. The topics to be covered by the Care Manager (CM) are informed and under-pinned by the guidelines for the management of people with coronary heart disease, including, attention being given to: 1) Appropriate reduction of clinical risk factors e.g. hypercholesterolaemia, hypertension and diabetes. 2) Lifestyle change of behavioural risk factors (smoking, nutrition, alcohol, physical activity, weight management). 3) Encouraging compliance with pharmacological management. 4) Management of psychological and social issues, particularly depression. Consistent with the self- and co-management approach underpinning the care management intervention, patients will be encouraged to follow-up relevant issues with their health provider(s), supported by appropriate ‘hard copy’ or electronic communication being sent to the patient’s doctor by the care manager and co-signed by one of team’s 3 research cardiologists. Subjects in the intervention group will receive the telephone-based care management program in addition to usual care.