Conference Targets Effective Chronic Disease Management

In June 1996, the Group Health Cooperative of Puget Sound and the Center for the Advancement of Health jointly sponsored a conference on the requirements for effective disease management.

The project was part of the Robert Wood Johnson Foundation (RWJF) Chronic Care Initiatives in HMOs national program.

Key Recommendations

  • Recommended system changes to support collaborative management of chronic illness included:

    • Better information systems to identify people with chronic illness, trigger preventive interventions, track disease and functional outcomes, and facilitate communication between patients and providers.
    • Health care teams with clearly defined roles and responsibilities for performing routine assessment, targeting, planning, and prevention.
    • Support opportunities for ongoing education and consultation between primary care and specialty providers.
    • Practice guidelines that direct provision of health care in accordance with scientific and relevant clinical expertise.
    • Guidelines for individual chronic conditions embedded in a general strategy for managing chronic illness in organized health care systems.
    • Well organized, highly accessible services that provide training and support for self- management.