Centralized population health coordinators help improve care for patients with chronic disease

Dec. 13, 2017

A centralized chronic disease management program produced significant improvements in the care of patients with diabetes, hypertension, or cardiovascular disease treated at practices in the Massachusetts General Hospital (MGH) primary care network. The results of a six-month pilot study, published in the American Journal of Managed Care, have led to expansion of the program to all practices in the MGH primary care network.

Population health management programs focus on the provision of care to a panel of patients through networks of individual clinical practices. In addition to the care provided at traditional, face-to-face patient visits, population health management also seeks to identify patients with chronic diseases who may need additional intervention to meet clinical goals, allowing practice staff to reach out to those patients rather than waiting for a patient-initiated visit. But it has not been clear whether non-visit-based population health activities should be handled by individual practice staff or centrally managed by network-based staff.

The current study was conducted within the MGH Primary Care Practice-Based Network, made up of 18 practices located at the hospital, at MGH-affiliated community health centers and in the greater Boston area. All network practices use electronic health records and a computerized practice management tool initially established for cancer screenings, which was expanded to include chronic disease registries—which compile data on the health status and care of patients with shared health needs—for diabetes, cardiovascular disease and hypertension.

To investigate the impact of centralized chronic disease management, four network-based population health coordinators were assigned to 8 of the 18 network practices in 2014. They received special training in chronic disease management, preventive health, health coaching, and use of the electronic health record and the clinical registries. They met regularly with practice physicians to review information on patients who needed additional clinical intervention and to develop action plans ranging from ordering overdue laboratory testing, to obtaining results of in-home blood pressure monitoring, to scheduling office visits.

Of the more than 160,000 patients cared for in the network, there were 12,316 with diabetes, 12,591 with cardiovascular disease, and 41,591 with hypertension. For each group of patients, the researchers compared outcomes—such as whether patients were receiving appropriate and timely testing and monitoring and whether they achieved clinical goals, such as target A1C levels for patients with diabetes or cholesterol levels for those with cardiovascular disease—at practices with centralized population health coordinators to those at practices without coordinators.

While all of the network practices showed significant increases in chronic disease outcomes during the six-month study period from July through December 2017, those improvements were measurably greater at practices where central population health coordinators worked closely with practice staff. Practices with coordinators showed greater improvement in the percentages of patients who received appropriate testing and in those who achieved clinical targets.

Massachusetts General Hospital has the full release

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