Managing Cardiometabolic Disease Is Key to Improving Health Outcomes in North Carolina

Am J Manag Care. 2026;32(Spec. No. 3):SP185-SP187. https://doi.org/10.37765/ajmc.2026.89910

Cardiovascular conditions are a significant health issue in North Carolina, with 19% of its residents dying of heart disease in 2022.¹ This indicates a high need for health care providers in North Carolina to focus on this specialty and offer accessible care for those who need it. At an Institute for Value-Based Medicine (IVBM) event held in Durham, North Carolina, on November 13, 2025, experts from Duke University School of Medicine and Novant Health discussed how to treat patients with cardiometabolic diseases and offered potential solutions to improving access to the care required to improve health outcomes in those with cardiovascular and cardiometabolic conditions.

Clinics Focusing on Heart Health Can Help Give Centralized Care

Making care easy to obtain by putting it under one roof helps guarantee that a patient sees all specialists and adheres to prescribed treatment. Thus, establishing clinics in North Carolina that employ doctors, nurses, and pharmacists across specialties is a key factor in improving outcomes for cardiovascular and cardiometabolic conditions. The first 2 presentations of the IVBM event highlighted successes and challenges in clinics established in recent years in North Carolina for this purpose.

John Rommel, MD, a cardiologist at Novant Health, shared the results of opening the HeartStrong Clinic, where patients can see doctors, nurse practitioners, physician assistants, nurses, and pharmacists in one place. HeartStrong Clinic was opened in 2015 and, over the past 10 years, has added specialized heart failure unit nursing care, been certified by CMS First Implant, and launched a Heart Healthy Holiday Readmission Reduction Initiative.

Patients who go to the outpatient clinic are encouraged to have follow-up visits at 1 week with an advanced clinical practitioner (ACP), 3 weeks with a nurse, 6 weeks with an ACP or doctor, and 3 months with a doctor. Pharmacists and nurses are also available to offer medication reconciliation, education, and medication assistance.

Challenges surrounding the inpatient aspect of the clinic include the changing population and treatment landscape, the need to adapt to the evolving literature in cardiology, and the additional “hands in the pot” in these settings, Rommel said.

Even with those challenges, however, Rommel emphasized that improvements could be made, including expanding the pulmonary hypertension clinic, enhancing remote monitoring platforms, and learning to care for patients living farther away. Goals should include learning how to improve care in rural regions, improving care as the technology changes, adapting to CMS payments, and incorporating new guidelines, he added.

Neha Pagidipati, MD, MPH, director of the Duke Cardiometabolic Prevention Clinic, gave a presentation on the efficacy of the clinic in addressing the needs of the area. Patients with cardiovascular-kidney-metabolic (CKM) syndrome, which can include diabetes along with heart failure and atherosclerotic cardiovascular disease (ASCVD), often fall through the cracks of health care due to the breadth of services that they need, she said.

According to results of a study published in the Journal of the American Heart Association,² 37.4% of individuals with diabetes and ASCVD were not taking any medication, and only 10% were taking glucagon-like peptide-1 (GLP-1) receptor agonists or sodium-glucose cotransporter 2 (SGLT2) inhibitors. Data from a separate study showed that just 11.2% and 8.0% of those in the Department of Veterans Affairs system were using SGLT2 inhibitors or GLP-1 receptor agonists, respectively, and those who were younger and White were more likely to be using these treatments.³

These gaps illustrate the need for clinics with a patient-centered implementation focus, which emphasizes consideration of social determinants of health, supports healthy lifestyles in communities, offers CKM education, and is implemented across health centers.

Duke Cardiometabolic Prevention Clinic’s goal, Pagidipati said, is to improve the health of the highest-risk patients within Duke with a coordinated team of cardiologists, endocrinologists, nephrologists, hepatologists, and pharmacists. Coordinated care can include biweekly team meetings to discuss patient cases to ensure alignment and frequent communication among specialists. Finding patients who require the highest care is often more difficult, as they often do not seek care. Identifying these patients can pinpoint where focus needs to be directed.

Although this model is potentially scalable due to minimal financial input from the health system and data infrastructure not being required, it is difficult to reach rural or distant patients through a single clinic, and experts need to be available to staff the clinic. Providing a pharmacist may also be difficult due to the high expense of CKM medications.

Expanding telehealth services, having pharmacists handle access to medications, and offering a CKM coordinator to help patients navigate their care are keys to expanding the reach of these clinics, Pagidipati said. Sustaining the model of a cardiometabolic clinic relies on having a local champion to keep the work going and health system leaders who support the effort.

“Interdisciplinary care models will be necessary to care for patients with CKM syndrome in a holistic way. These models will need to include pharmacists to help manage therapies, [advanced practice practitioners] to drive clinical algorithms, and a CKM coordinator to help navigate complex care,” Pagidipati said.

Pharmacists Play Major Role in Managing Patients’ Cardiometabolic Health

Pharmacists collaborate not only in clinics but also in practice outside of those clinics. Experts at the IVBM event acknowledged the role that pharmacists play in balancing patients’ cardiometabolic health.

Jerry Rebo, PharmD, MBA, BCPS, BCCCP, DPLA, director of pharmacy value and outcomes at Novant Health, discussed how pharmacists can help to manage populations and their medical needs. Rebo highlighted that the pharmacy value and outcomes team has collaborated to develop evidence-based strategies, including one to address iron deficiency anemia in presurgical patients.

He also highlighted Mediful, a virtual service offered by clinical pharmacist practitioners (CPPs) that helps patients navigate Novant’s health care system. The pharmacists also check all medications to ensure the best costs and improve outcomes. Patients can be referred to Mediful, where they will meet with a CPP virtually before the CPP prescribes medication that can be delivered to the patient’s home. Follow-up appointments are scheduled to monitor the patient, and updates to the primary care provider are offered to ensure a holistic approach to the patient’s care.

According to Rebo, Mediful has been associated with reduced hospital readmissions and lower 30-day return rates to the emergency department in patients with diabetes. This yielded an estimated $5.2 million in cost avoidance in 2023 and 2024 combined, he said. With Mediful partnering with Novant Health for a chronic disease management program, the goal is to target beneficiaries and team members with diabetes, hypertension, or both. Those requiring enhanced care will be separated from those meeting clinical goals to address each as needed. The program launched in January 2026, and data will be forthcoming on its impact and how to guide continuous improvement.

Benjamin Smith, PharmD, BCACP, BCGP, CPP, associate chief pharmacy officer of population health and ambulatory services at Duke University Health System (DUHS), also discussed how pharmacy interventions can further the goal of population health.

DUHS, he said, aims to improve population health while reducing costs, improving clinician and staff well-being, and advancing health equity. The staff pharmacists provide support such as navigating prior authorization and medication access barriers. Under physician supervision, CPPs can offer health care services throughout North Carolina, making collaboration easier. This can also improve health care outcomes for both their patients and others, as results of a study have found that CPPs improved evidence-based prescribing by providers in the clinics with a pharmacist for patients not seen by the CPP.⁴

Ultimately, value will be measured through clinical metrics, patient satisfaction, reduced preventable utilization, and impact on quality measures and value-based payer arrangements.

Smith closed by pointing to the broad potential for pharmacist-led interventions to improve patient outcomes across primary care, specialty care, and population health settings. As population health strategies continue to evolve alongside shifting priorities, he emphasized the importance of establishing clear

measures of success, demonstrating value before implementation, and allowing programs to be refined when results fall short of expectations.

More broadly, the speakers underscored that sustained collaboration between pharmacists and clinicians—whether embedded within a single clinic or coordinated across health systems—will be critical to improving care for patients with cardiometabolic disease in North Carolina. If successful, such programs could help expand access to more personalized care and support better outcomes for patients statewide.

Author Information:Ms Bonavitacola is an employee of MJH Life Sciences, the parent company of the publisher of Population Health, Equity & Outcomes.

REFERENCES

1. What are the leading causes of death in North Carolina? USAFacts. Updated July 19, 2024. Accessed January 13, 2026. https://usafacts.org/answers/what-are-the-leading-causes-of-death-in-the-us/state/north-carolina/
2. Nelson AJ, Ardissino MA, Haynes K, et al. Gaps in evidence-based therapy use in insured patients in the United States with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. J Am Heart Assoc. 2021;10(2):e016835. doi:10.1161/JAHA.120.016835
3. Mahtta D, Ramsey DJ, Lee MT, et al. Utilization rates of SGLT2 inhibitors and GLP-1 receptor agonists and their facility-level variation among patients with atherosclerotic cardiovascular disease and type 2 diabetes: insights from the Department of Veterans Affairs. Diabetes Care. 2022;45(2):372-380. doi:10.2337/dc21-1815
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