In the Tribal Communities of California's Pauma Valley, it Takes a Village to Combat Chronic Illness

Implementing the Chronic Care Model

Field of Work: Implementing the Chronic Care Model

Problem Synopsis: The health of American Indians and Alaska Natives is among the poorest of all U.S. racial and ethnic groups; about one in five Native adults has two or more chronic health problems.

Synopsis of the Work: A health clinic operated by the Indian Health Council in rural Pauma Valley north of San Diego implemented the Chronic Care Model through participation in Planned Care, a year-long Breakthrough Series Collaborative. Six areas of patient health were targeted: alcohol misuse, depression, domestic violence/intimate partner violence, tobacco use, obesity and blood pressure.

Key Findings/Results: After a year in the pilot program, clinic staff redesigned care delivery throughout the medical clinic to reflect the new team approach to chronic illness care. This has resulted in consistent improvement in alcohol misuse screening, colorectal cancer screening and childhood immunizations; decreased office visit cycle time; and improved continuity of care. Physical activity and exercise referrals have increased, and patients are taking control of their own personal health and well being.

Most Requested