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Improving Chronic Care
When Premier Health Partners of Dayton, Ohio set out to
improve the care and outcomes of patients with diabetes, it
started with physicians. The plan gave doctors a comprehensive
Diabetes Innovation Tool Kit, which contained materials to
help streamline medical records and keep physicians up-to-date
on the latest diabetes research. Premier also improved the
quality of diabetes care by outfitting examination rooms with
the necessary tools to conduct foot exams, which are critical
to appropriate management of the disease. The health plan
worked collaboratively with medical staff to support patients
in self-management of the disease. All of these efforts were
supported by the five-year, $25-million Improving Chronic
Illness Care (ICIC) program. ICIC has demonstrated that
changes like the ones instituted by Premier Health Partners
can result in better health outcomes for chronically ill patients.
The cornerstone of ICIC is the evidence-based Chronic Care
Model, which summarizes the basic elements for improving care
in health systems at the community, organization, practice
and patient levels. This model will be used as part of the
Foundation’s $6.3-million, two-pronged initiative to
tackle diabetes. The Centers for Disease Control reported
that diabetes reached epidemic proportions in 2001, and today,
an estimated 17 million people have the disease. Most of the
health care costs associated with diabetes—some $100
billion a year—could be reduced through better self-management
and more coordinated care. One new program, Advancing Diabetes
Self-Management, will award six sites up to $300,000 each
to develop and test a diabetes self-management program for
primary care settings. A second program, Building Community
Supports for Diabetes Care, will award up to $125,000
for 12 months to eight provider/community coalitions to plan
and test prevention and self-management activities in culturally
and ethnically diverse areas.
Diabetes is just one disease in which enhancing the patient’s
role has generated positive results. However, few primary
care practices understand how to promote this type of behavior
and work in partnership with patients to develop better self-management
processes. To address this gap, the Foundation launched the
first phase of its Co-Management Learning Network this year,
providing $1.5 million in planning grants to design and disseminate
patient-centered approaches throughout the health care field.
Improving Chronic Care in Publicly-Funded Health Plans
More than half (56 percent) of those enrolled in Medicaid
received care through a managed care plan in 2000, nearly
a sevenfold increase from 1991. Approximately 80 percent of
Medicaid resources are spent on those with chronic conditions.
The Foundation’s $60-million Medicaid Managed Care
Program focuses on that managed care segment of the
Medicaid arena. The program, based at the Center for Health
Care Strategies, supports Medicaid managed care plans to develop
new ways to deliver quality, coordinated chronic care services.
For example, a plan in Minnesota has improved the coordination
of care for up to 500 enrollees with physical disabilities.
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