Assessing Outcomes of Enhanced Chronic Disease Care Through Patient Education and a Value-based Formulary Study

The purpose of this study is to determine the effect of two novel interventions; (1) a value-based formulary which eliminates copayment for selected high-value medications (proven to prevent heart attacks, stroke, and hospitalizations); and (2) a comprehensive patient education program aimed at lifestyle modification and optimal drug use, combined with relay of information on medication use, on the risk of adverse clinical outcomes (mortality, heart attack, stroke, need for coronary revascularization, and chronic disease related hospitalizations) in low-income seniors with chronic conditions over three years of follow-up or until March 31, 2021 (whichever comes first).

Inclusion Criteria: \>65 years of age (have drug insurance from Alberta Blue Cross with 30% copayment) Have any one of the following: * coronary disease * prior stroke * chronic kidney disease * heart failure OR any two of the following: * current cigarette smoking (\>1/2 pack per day) * diabetes mellitus * hypertension * hypercholesterolemia Have total family income \