The Guidelines Applied in Practice (GAP) initiative provides a regional systematic approach for identifying and ensuring all patients hospitalized with Acute Coronary Syndrome (ACS) are receiving best practice guidelines upon discharge from hospital. Safety research confirms patients experience complications and adverse drug effects when transitioning from hospital to home. Adherence to cardiac medications declines sharply during the first six months post discharge. Recognizing that medication noncompliance is linked to poor health outcomes and increased adverse events the University of Ottawa Heart Institute designed an interactive voice response (IVR) system to support patients after discharge following an ACS event. This is an outbound calling system designed to assist patients to remain on best practice guidelines. It’s a companion system to ACS GAP regional program to follow patients to one year post discharge to maintain compliance with ACS best practice. All ACS patients are called at 1,3,6,9, and 12 months. Each call asks specific questions about medications prescribed on discharge and determines whether or not they remain on guidelines. When patients indicate they are no longer taking guideline medication, they are called by an RN and efforts are made to return the patient to best practice guidelines through discussion with family physician. There are also questions on lifestyle issues including diet, smoking cessation, activity etc. Our follow-up calls have identified issues with prescription practices; provider knowledge deficits; patient knowledge deficits and social/financial issues. We provide this service to all our ACS patients discharged home and to our regional patients.

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