The Instruction Manual for Designing Health Care Delivery in Battle Creek, Mich.

Improving Chronic Illness Care

Field of Work: Implementing the Chronic Care Model

Problem Synopsis: Even before the 2008 recession that hobbled the automobile industry on which it is so dependent, Battle Creek, Mich., a town of 52,000, had an anemic economy and depressing health statistics. In Calhoun County, where Battle Creek is located, 10 percent of adults have diabetes, with an additional 40 percent pre-diabetic. In addition, more than 70 percent of residents in Calhoun County are overweight or obese.

Synopsis of the Work: In 2007, Integrated Health Partners, a group of some 170 affiliated physicians in the Battle Creek, launched a learning collaborative with local physicians and practice teams interested in implementing the Chronic Care Model. Subsequently, the work expanded to include people all along the continuum of care for chronically ill patients: physicians in solo practice, discharge planners in hospitals, employers, social service agency workers and others.

Key Findings/Results: By the end of 2010, the effort was beginning to show results in improved patient outcomes. Some 25 percent of diabetes patients and nearly 50 percent of cardiovascular disease patients had physicians who had participated in a Chronic Care Model learning collaborative.

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