STRATEGIES FOR CHRONIC CARE IS GROUNDED IN POPULATION HEALTH MANAGEMENT

Population health management is an approach considered to be fundamental to the transformation of healthcare and an integral part of the Quadruple Aim to improve the patient experience of care, improve the health of populations, and reduce the per capita cost of healthcare, and improve provider satisfaction.1

The objective of Strategies for Chronic Care™ is to help providers better manage their population of chronic care patients across the care continuum. Strategies for Chronic Care provides resources for providers and patients with an emphasis on team-based, patient-centric care, treatment adherence, and patient self-management.

–POPULATION HEALTH MANAGEMENT STRATEGIES TO HELP ACHIEVE THE QUADRUPLE AIM1

Population Identification Processes
Population Identification Processes act as a starting point for an integrated approach to healthcare by providing a standardized way to identify and stratify chronic disease patient populations.
Evidence-Based Practice Guidelines
Evidence-Based Practice Guidelines provide a road map for implementing evidence-based practices into workflows to improve outcomes for patients with chronic diseases.
Coaching and Collaborative Practice Models
Coaching and Collaborative Practice Models offer ways to implement a team-based care approach to improve the engagement and overall management of patient populations with chronic diseases.
Patient Self-Management Education
Patient Self-Management Education enables and empowers patients to better self-manage their chronic disease. Validated processes to improve self-management can be integrated into practice workflows, including:
  • Patient Activation Assessments
  • Patient Outcomes Support (Education)
  • Patient/Provider Engagement Through Motivational Interviewing
Care Coordination
Care Coordination between providers (ie, specialists and primary care), institutions (ie, hospital and community-based providers), and care teams (ie, providers and patients) is a critical component to ensure a standardized approach to patient management, close existing gaps, and improve outcomes.
Monitoring/Process and Outcomes Measurement
Monitoring/Process and Outcomes Measurement provides a simple yet comprehensive repository of the key policy decisions, marketplace trends, and best practices that will increase understanding and application of quality-improvement measures in the practice setting.
References:
1. Reference: Bodenheimer T, Sinksy C. Ann Fam Med. 2014; 12:573-76
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