White paper
Identifying Best Practices in Cardiometabolic Care Programs
Authors
Affiliations
Commissioned by Eli Lilly and Company
Introduction
Cardiometabolic diseases, such as obesity, type 2 diabetes, and cardiovascular disease, are a growing U.S. health challenge, driving high costs and risks when managed in silos.
This white paper reviews 39 U.S. cardiometabolic care programs (CMPs) from 2014–2024, identifying evidence-based best practices in these models to provide a framework for consideration in the future design and implementation of effective CMPs for high-risk populations.
...the total cost impact of obesity-related complications is “beyond additive,” with total costs reaching
151%, 218%
and 264% of the sum costs
of the individual complications for class 1, class 2, and class 3 obesity, respectively...
Findings
The white paper found that most CMPs delivered measurable health gains, including weight loss, lower blood pressure, improved lipid profiles, and better HbA1c control. Successful programs shared best practices such as multidisciplinary teams, clinical practice aligning with evidence-based guidelines, personalized care, consistent follow-ups, and effective communication.
Technology-enabled monitoring, targeted care for high-risk patients, and attention to social determinants were also key, while telehealth showed promise for expanding access.
Recommended Best Practices for Cardiometabolic Care Programs
Team-based multidisciplinary approach
Use of evidence-based guidelines
Patient-centered individualized care
Accessible
Comprehensive care
Regular follow-ups
Addressing social determinants
Ample time for program duration
Targeting populations at high risk for appropriate comprehensive care
Leveraging technology for effective communication and dissemination of program information
Case Studies
This white paper highlights several real-world examples of CMPs that successfully improved patient outcomes by applying the identified best practices. These programs span healthcare clinics, pharmacist-managed care, employer-based initiatives, and telehealth models, yet all share a commitment to coordinated, patient-centered care.
Featured Programs
- PHASE (Preventing Heart Attacks and Strokes Every Day) – Kaiser Permanente Northern California
- CINEMA (Center for Integrated and Novel Approaches in Vascular-Metabolic Disease) – University Hospitals Cleveland Medical Center
- Pharmacist-Managed CVRR Clinics – Federally Qualified Health Centers, Indiana
- My Unlimited Potential (MyUP) – Baptist Health South Florida
- eCMP (Electronic Cardiometabolic Program) – Northern California outpatient multispecialty group practice