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Published Online: 8 February 2006

Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology

Publication: Disease Management
Volume 9, Issue Number 1

Abstract

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed. (Disease Management 2006;9:1–15)

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cover image Disease Management
Disease Management
Volume 9Issue Number 1February 2006
Pages: 1 - 15
PubMed: 16466338

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Published online: 8 February 2006
Published in print: February 2006

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David A. Dorr, M.D., M.S.
Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon.
Adam Wilcox, Ph.D.
Department of Medical Informatics, University of Utah, Salt Lake City, Utah.
Intermountain Healthcare, Salt Lake City, Utah.
Laurie Burns, P.T., M.S.
Intermountain Healthcare, Salt Lake City, Utah.
Cherie P. Brunker, M.D.
Intermountain Healthcare, Salt Lake City, Utah.
Scott P. Narus, Ph.D.
Department of Medical Informatics, University of Utah, Salt Lake City, Utah.
Intermountain Healthcare, Salt Lake City, Utah.
Paul D. Clayton, Ph.D.
Department of Medical Informatics, University of Utah, Salt Lake City, Utah.
Intermountain Healthcare, Salt Lake City, Utah.

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