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Implementing a multidisease chronic care model in primary care using people and technology
David A Dorr1, Adam Wilcox, Laurie Burns
1Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA. dorr@ohsu.edu
Disease Management : DM
|February 10, 2006
Summary
Intermountain Healthcare improved chronic disease management using a generalist model, integrating care managers and electronic health records (EHRs) in primary care clinics. This approach enhances patient outcomes and physician productivity for diverse, coexisting conditions.
Area of Science:
- Healthcare Management
- Chronic Disease Care
- Primary Care Innovation
Background:
- Chronic disease management in the US faces challenges like healthcare system fragmentation and lack of team-based care.
- Specialized, single-disease programs may struggle with comprehensive care for patients with multiple conditions.
Purpose of the Study:
- To present Intermountain Healthcare's generalist model for chronic disease management.
- To describe how this model overcomes limitations of specialized care and addresses complex patient needs.
Main Methods:
- Implemented a generalist model within primary care clinics, featuring care managers collaborating with physicians and patients.
- Utilized an electronic health record (EHR) system for data access, decision support, and provider communication.
- Applied the model to manage diverse patients with multiple, coexisting chronic conditions.
Main Results:
- Demonstrated improved patient outcomes in chronic disease management.
- Showcased enhanced physician productivity through integrated care approaches.
- Identified key success factors, challenges, and obstacles in model implementation.
Conclusions:
- The generalist model, incorporating care managers and EHRs, effectively improves chronic disease management.
- This integrated approach offers a viable solution for complex, multi-condition patient care within primary care settings.