Targeted CVD Patient Identification and Guideline-Aligned Therapy Optimisation

Case Study (UK)

Summary

Inizio Engage Patient Solutions partnered with an NHS Primary Care Network (PCN) to identify, screen and support high-risk patients with cardiovascular disease (CVD) who were non-adherent, disengaged or missing routine reviews.

Over a six-month period, Inizio Engage nurse-led outreach identified at-risk individuals, provided lipid management education, and facilitated clinician referrals – strengthening secondary prevention pathways, enabling appropriate therapy identification, and supporting improved cardiovascular risk management within primary care.

In Detail

The Challenge

Identifying and Re-engaging High-Risk Cardiovascular Patients in Primary Care

Cardiovascular disease remains a leading cause of morbidity and mortality in the UK. Secondary prevention strategies are critical for patients already identified as high risk.

Our client provides an evidence-based prescription therapy indicated to reduce cardiovascular risk in appropriate high-risk patients. However, in busy primary care settings, identifying eligible patients, reviewing lipid management, and ensuring alignment with secondary prevention guidelines can be resource-intensive.

To support appropriate patient identification and therapy optimisation within real-world clinical practice, the client sought a structured, compliant engagement model embedded within primary care.

​​Our Solution​

A Nurse-Led Cardiovascular Risk Screening and Outreach Model

Inizio Engage Patient Solutions deployed a specialist nurse team embedded within two practices in a Primary Care Network (PCN).

The nurses:

• Identified high-risk and non-adherent patients using the PCN’s patient management system
• Conducted structured telephone outreach
• Reviewed patient health status and cardiovascular risk factors
• Delivered disease education and lifestyle reinforcement
• Provided lipid management guidance and medication support
• Documented all interactions within the PCN system
• Escalated appropriate patients to clinicians for further assessment

All nurses were:

• Trained in lipid management
• Trained across relevant cardiovascular medications
• Fully onboarded to the PCN-specific clinical systems
• Integrated into the primary care workflow

This model ensured seamless collaboration between Inizio Engage nurses and NHS clinicians.

The Inizio Engage Impact​

Measurable Impact on Cardiovascular Risk Management in Primary Care

The programme enabled structured identification of high-risk patients, supported clinician-led review, and strengthened alignment with secondary prevention guidelines.

The initiative also strengthened collaboration between primary care and the client by embedding a compliant, nurse-led engagement model that facilitated guideline-aligned clinical review in routine practice.

By combining nurse-led outreach with embedded primary care collaboration, the initiative supported appropriate therapy optimisation while reinforcing the client’s commitment to improving cardiovascular outcomes in routine practice.