Penn Medicine Heart Program Extends Care Beyond Office Visits

Philadelphia-based Penn Medicine has launched a program that takes advantage of risk stratification and text messaging to help patients lower the risk of hypertension and hypercholesterolemia.


Given the health and economic benefits of reducing atherosclerotic cardiovascular disease (ASCVD) risk and the burden on clinicians posed by conventional population health approaches, Penn Medicine launched the ASCVD Risk Reduction Initiative in June 2021 to enhance the ways that primary care clinicians help patients improve their heart health. The initiative is focused on patients with or at high risk of ASCVD.

The ASCVD Risk Reduction Initiative’s flagship program is Penn Medicine Healthy Heart (PMHH), which applies behavioral economics insights to increase uptake of and adherence to evidence-based interventions to reduce the risk of ASCVD. The goal is to help patients take action to reduce their heart disease risk by lowering their blood pressure and cholesterol from home. 

Penn Medicine described the program as being designed to relieve overburdened primary care providers through automated “hovering” technology coupled with a centralized team of non-clinical navigators and nurse practitioners. It emphasizes proactive outreach and prevention outside of a traditional visit model and the use of data assets to identify and risk-stratify patients.

Using tools such as remote blood pressure monitoring, cholesterol counseling, medication management, personalized healthy eating resources, and smoking cessation support delivered via text, phone, and video, the goal is to make the expertise of Penn Medicine care staff more accessible. 

In a blog post, Marguerite Balasta, M.D., medical director of PMHH, and Kevin Volpp, M.D., Ph.D., the principal investigator of PMHH and director of the Penn Center for Health Incentives and Behavioral Economics, answered a series of questions to explain how the program works.
Balasta and Volpp were asked about using tools to monitor patients outside of the clinical environment.

The researchers said that patient needs can be more frequently addressed between office visits rather than waiting weeks or months until the next appointment to make changes in blood pressure and cholesterol management. Combining hovering with a centralized team working in collaboration with PCPs helps to improve patients' cardiovascular health and create a supportive experience for patients.  

Although the program includes automated text messages, each patient will also have the opportunity to build a relationship with a navigator accessible via two-way text messages and phone calls. 


The hope is that the six-month program will lead to lower blood pressures and lower cholesterol for patients. The researchers will also be interviewing patients and providers to learn from their experiences.

The trial will run from February 2024 to approximately April 2025 as they enroll patients in four batches. Eligible patients will be identified by the PMHH team in collaboration with their primary care providers and contacted by text message.

Based on trial results, they hope to scale up the Healthy Heart program into normal clinical care and expand enrollment to more patients who could benefit at Penn Medicine and potentially across the region.