In June 1996, the Group Health Cooperative of Puget Sound and the Center for the Advancement of Health jointly sponsored a conference on the requirements for effective disease management.
The project was part of the Robert Wood Johnson Foundation (RWJF) Chronic Care Initiatives in HMOs national program.
Recommended system changes to support collaborative management of chronic illness included:
- Better information systems to identify people with chronic illness, trigger preventive interventions, track disease and functional outcomes, and facilitate communication between patients and providers.
- Health care teams with clearly defined roles and responsibilities for performing routine assessment, targeting, planning, and prevention.
- Support opportunities for ongoing education and consultation between primary care and specialty providers.
- Practice guidelines that direct provision of health care in accordance with scientific and relevant clinical expertise.
- Guidelines for individual chronic conditions embedded in a general strategy for managing chronic illness in organized health care systems.
- Well organized, highly accessible services that provide training and support for self- management.