Population Management, Systems-Based Practice, and Planned Chronic Illness Care: Integrating Disease Management Competencies into Primary Care to Improve Composite Diabetes Quality Measures

摘要

The increasing prevalence of chronic illnesses in the United States requires a fundamental redesign of the primary care delivery system's structure and processes in order to meet the changing needs and expectations of patients. Population management, systems-based practice, and planned chronic illness care are 3 potential processes that can be integrated into primary care and are compatible with the Chronic Care Model. In 2003, Harvard Vanguard Medical Associates, a multispecialty ambulatory physician group practice based in Boston, Massachusetts, began implementing all 3 processes across its primary care practices. From 2004 to 2006, the overall diabetes composite quality measures improved from 51% to 58% for screening (HgA1c × 2, low-density lipoprotein, blood pressure in 12 months) and from 13% to 17% for intermediate outcomes (HgA1c ≤7, low-density lipoprotein ≤100, systolic blood pressure ≤130). Over the same period, a secondary retrospective cohort analysis noted greater gains in composite screening and intermediate outcome measures for patients with planned visits compared to those who had no planned visits. This study illustrates how 1 delivery system integrated these disease management functions into the front lines of primary care and the positive impact of those changes on overall diabetes quality of care. (Disease Management. 2008;11:13–22)