This document discusses care coordination for patients with chronic conditions. It notes that chronic diseases account for most deaths in the US and nearly half of all Americans live with at least one chronic illness. Proper care coordination is important for managing chronic conditions but can be challenging to implement. The Patient-Centered Medical Home model aims to improve chronic care coordination and management but also faces difficulties in implementation that some see as investments needed to better serve patients.

1. April 2012 2nd Quarter 2012. Vol.2
SYSTEMS CHANGE NEWS
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Care Coordination for Patients with Chronic For
full
article
go
to:
Conditions http://daoconsultingservices.blogspot.com/2012/03/care-­‐
coordination-­‐for-­‐patients-­‐with.html
Historically,
public
and
private
health
organizations
have
"Assessing and Increasing Readiness for
tried
and
continue
trying
to
improve
the
quality
of
care
for
patients
with
chronic
conditions.
The
following
statistics
Patient-Centered Medical Home
were
published
by
the
Center
for
Disease
Control
and
Implementation"
Prevention:
Many
health
care
institutions,
health
centers,
and
individual
• 7
out
of
10
deaths
among
Americans
each
year
are
from
practitioners
are
familiar
with
the
Patient-­‐Centered
Medical
chronic
diseases.
Heart
disease,
cancer
and
stroke
Home
Model.
Many
of
them
know
first-­‐hand
the
account
for
more
than
50%
of
all
deaths
each
year.
importance
of
taking
the
best
practices
of
successful
PCMH
• In
2005,
133
million
Americans
–
almost
1
out
of
every
2
implementations,
it
increases
patient
satisfaction,
lower
adults
–
had
at
least
one
chronic
illness.
cost,
improves
staff
moral,
and
increases
patient
quality
of
• Obesity
has
become
a
major
health
concern.
1
in
every
3
care.
However,
there
are
many
challenges
involved
in
adults
is
obese
and
almost
1
in
5
youth
between
the
ages
implementing
the
PCMH
model,
from
financial,
workforce
of
6
and
19
is
obese
(BMI
≥
95th
percentile
of
the
CDC
demands,
time,
and
others.
It
is
important
to
focus
on
the
growth
chart).
bigger
picture,
which
is
to
improve
quality
of
care
and
• About
one-­‐fourth
of
people
with
chronic
conditions
have
reduce
cost.
For
that,
practices
desiring
or
in
the
beginning
one
or
more
daily
activity
limitations.
process
of
PCMH
implementation
should
see
certain
• Arthritis
is
the
most
common
cause
of
disability,
with
"challenges"
as
investments.
For
example,
staff/or
nearly
19
million
Americans
reporting
activity
limitations.
physicians
time
to
discuss
the
desire
and
need
to
get
stared
• Diabetes
continues
to
be
the
leading
cause
of
kidney
with
the
PCMH
implementation.
This
is
a
required
failure,
non-­‐traumatic
lower-­‐extremity
amputations,
and
investment
from
the
physician
and
practice
part
as
it
is
an
blindness
among
adults,
aged
20-­‐74.
investment
when
coordinating
PCMH
implementation
teams.
In
many
situations
there
are
practices
that
see
the
Unfortunately
this
statistics
may
not
change
for
the
better,
PCMH
model
as
a
burden,
instead
of
an
opportunity
to
be
if
not,
increase
affecting
million
more
Americans.
A
chronic
humble
and
take
the
responsibility
of
investing
in
the
quality
condition
is
the
state
of
the
disease
that
usually
will
last
for
of
care
for
their
patients.
It
is
always
better
to
breakdown
more
than
one-­‐year
without
significant
improvement
and
big
projects
into
manageable
and
doable
tasks
to
focus
on
debilitating
the
individual
in
many
different
functions
of
his
specific
areas
to
reach
success
in
making
changes.
life,
physically
and
mentally.
To
care
for
an
individual
with
a
For
full
article
go
to:
chronic
condition,
it
requires
extensive
care
coordination
http://daoconsultingservices.blogspot.com/2012/03/assessing-­‐
and
follow-­‐up.
and-­‐increasing-­‐readiness-­‐for.html
In
another
statics
release
by
the
Improving
Chronic
Illness
Care,
a
national
organization,
show
that
more
than
Our Mission is to help healthcare leaders
145
million
people,
or
almost
half
of
all
Americans,
live
with
improve the quality of care through innovative
a
chronic
condition.
That
number
is
projected
to
increase
by
and measurable quality improvement
more
than
one
percent
per
year
by
2030,
resulting
in
an
strategies, and create sustainable changes in
estimated
chronically
ill
population
of
171
million.
Almost
half
of
all
people
with
chronic
illness
have
multiple
their communities.
conditions.
As
a
result,
many
managed
care
and
integrated
delivery
systems
have
taken
a
great
interest
in
correcting
Published
by
the
many
deficiencies
in
current
management
of
diseases
Dao
Management
Consulting
Services,
Inc.
such
as
diabetes,
heart
disease,
depression,
asthma
and
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Side
Avenue,
Suite
255,
Jersey
City,
NJ
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others.
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