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Evaluation of a Chronic Care Management Model for Improving Efficiency and Fiscal Sustainability
Margaret A Kadree1, Patrick Wiggins1, Lura Thompson1
1Margaret A. Kadree is with the Johnson Federally Qualified Health Center, Lynchburg, VA. Margaret A. Kadree and Patrick Wiggins are with the Division of Prevention and Health Promotion, Virginia Department of Health, Richmond. Lura Thompson is with Care Connexion Rx Richmond, Richmond. Cynthia Warriner and Michelle White are with Health Quality Innovators, Richmond.
Abstract:
Chronic care management is effective. Barriers to program durability include dependence on the provider-nurse duo to carry out labor-intensive services and the lack of a fiscally sustainable model. Between January and October 2022, an expanded chronic care management team-consisting of a provider, nurse, community health worker, and pharmacist-conducted a four-month intervention in an ambulatory setting. This intervention, using a convenience sample of 134 Medicare patients with uncontrolled type 2 diabetes or hypertension, demonstrated statistically significant improvements in controlling type 2 diabetes (P < .01) and blood pressure (P < .001). Direct provider workload decreased, and the Medicare reimbursement rate was 85.5%. (Am J Public Health. 2025;115(2):133-137. https://doi.org/10.2105/AJPH.2024.307886).
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