From 1995 to 1996, researchers at the Kaiser Foundation Hospitals Research Institute in Portland, Ore., studied the feasibility of improving coordination of care for working-age adults with two or more chronic medical conditions.
Researchers analyzed data on patients' health care utilization and information gathered from patient interviews.
The project was part of the Robert Wood Johnson Foundation (RWJF) Chronic Care Initiatives in HMOs national program.
Looking at patterns of prescribed medicines is a low-cost, reliable method of identifying persons with multiple chronic illnesses.
Clinics that serve geographic areas characterized by low socioeconomic levels and that have large populations of African Americans tend to have a high prevalence of 20 to 64 year-old enrollees with multiple chronic medical conditions.
Enrollees who saw three or more primary care physicians over a one-year period had poorer outcomes than those who saw only one or two primary care physicians.
The project recommended that existing or evolving programs of care coordination in Kaiser focus on:
- Improving surveillance of patients with multiple chronic and medical conditions.
- Detecting patterns where poor patient outcome is associated with management by more than one physician, e.g., allowing those patients to be seen by only one physician.
- Improving medication management.
- Improving pain management.
- Reducing the incidence of risky behaviors, particularly smoking and overweight, which affect long-term management of chronic illnesses such as diabetes, circulatory disorders and/or obstructive pulmonary disorders.