Chronic Care Initiatives in HMOs

An RWJF National Program

Dates of Program: October 1992 through August 1999

Field of Work: Identifying, demonstrating, evaluating, and disseminating innovations in the health care of chronically ill people enrolled in prepaid managed care organizations.

Problem Synopsis: The nation's health care system is organized to diagnose and treat acute conditions such as broken bones and infectious diseases. This focus does not address the needs of patients suffering from such chronic conditions as diabetes and congestive heart failure. Chronic conditions are, by definition, lifelong. Many require continuous monitoring by a physician. The inadequacy of the acute care model for patients with chronic care needs had not been addressed in the rapid shift from fee-for-service health care to managed care plans occurring in the early 1990's.

Synopsis of the Work: Chronic Care Initiatives in HMOs was charged with identifying, demonstrating, evaluating, and disseminating innovations in the health care of chronically ill people enrolled in prepaid managed care organizations. The program's 18 projects included assessment and research on interventions for at-risk seniors, for mothers and children, and for working-age adults.

Key Results

  • Staff at the national program office cited the following results as having the most significance for the future management of chronic illness in managed care settings:

    • Creation of performance measures developed by the National Committee for Quality Assurance that assess how well a managed care organization is caring for chronically ill enrollees.
    • Creation of a screening tool that reliably identifies senior enrollees at high risk of frequent hospitalization.
    • Provision of primary managed care within specialized chronic care clinics.
    • Regional expansion of a cooperative health care clinic that has improved both patient and physician satisfaction.
    • Recommendations, opportunities and challenges in care management practices for chronically ill older patients.