Chronic Disease Prevention and Control

Metrics for this project are currently in draft form and are being updated by the Health Care Authority. The metrics under consideration include:

• # of health care providers trained in appropriate blood pressure assessment practices
• # of new / expanded nationally recognized self-management support programs (e.g., CDSMP, NDPP)
• # of partners participating / implementing each selected model / approach
• # of partners trained on selected model / approach: projected vs actual and cumulative
• # of home visits for asthma services, hypertension
• % of documented, up-to-date Asthma Action Plans
• % of patients provided with automated blood pressure monitoring equipment
• Child and Adolescents’ Access to Primary Care Practitioners
• Comprehensive Diabetes Care: HbA1c Testing
• Comprehensive Diabetes Care: Medical attention for nephropathy
• Outpatient Emergency Department Visits per 1000 Member Months
• Medication Management for People with Asthma (5 – 64 Years)
• Statin Therapy for Patients with Cardiovascular Disease (Prescribed)
• Comprehensive Diabetes Care: Eye Exam (retinal) performed

Implemented or expanded use of evidence-based models such as the Chronic Care Model. Informed, supported, and activated consumers, clinicians, and communities. Prepared and proactive health care system, placing more emphasis on prevention to avoid costly treatment.
Reduce number of risk factors, incidence, and relevance of chronic disease decrease, increased access to preventive health services, reduce health disparities, reduce health cost while increasing access to care.
• Raise awareness of chronic disease prevention through community outreach and education
• Educate doctors and nurses on chronic disease prevention and treatment
• Increase frequency of preventative screenings for common chronic diseases
• Expand community paramedicine resources (EMS)
• Improve coordination between medial and community resources for high-risk patients

The Chronic Care Model is an organizational approach for caring for people with a chronic disease in the primary care setting. The system creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive health care team. The Chronic Care Model supports the overall goal of transitioning to value-based purchasing by reducing the number of admissions and readmissions, improving patient self-management, and controlling costs.

Community paramedicine is an emerging model of community-based health care in which paramedics and EMTs operate in expanded roles to provide routine health care services to underserved populations. Perhaps the best demonstrated benefit of CP programs has been in getting persons who accessed the EMS system, but do not have a medically emergent condition, to more appropriate destinations than a hospital ED. This may yield financial savings and, in some cases, improve the coordination and continuity of care.

You might be interested in the Chronic Disease Prevention and Control project if you see patients with chronic diseases such as asthma, heart disease, and diabetes and want to reduce chronic disease through education and early screenings. The Transformation can expand prevention, self-management services, and annual screenings already in place or create new services to bridge the gap.

Project Work Group is working on:

1. Current state assessment
2. Identify Domain 1 strategies that support project
3. Finalize target populations and evidence-based approaches
4. Determine partnering providers
5. Complete implementation plans
6. Plan describing regional transition to fully-integrated managed care

Project Implementation in 2019, and scaling-up in 2020.

A healthy lifestyle is critical to the prevention and treatment of chronic disease, and it’s a lot harder to be healthy if you don’t have a job or a home or enough food. CPAA is committed to working with health care providers and other community-based social services to address health inequities like stable housing, healthy food, health literacy, and reliable transportation to appointments.
This project includes increasing healthy lifestyle habits, regular check-ups with the doctor, preventative screenings, and educational and supportive classes.

For more information, contact Kwabana Amoah-Fortson at amoahk@crhn.org