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Chronic Care Management

Improving chronic care can help reduce costs and boost quality of life. What can we do to provide the best care and the best outcomes for people with chronic illness?

UCLA Health CKD Risk Stratification and Management

Care Redesign

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease and to modify care processes and personnel has led to improved health and reduced utilization.

Telehealth and remote monitoring are little used and ineffective for chronic disease care

Care Redesign

Survey Snapshot: Treating Chronic Disease Proactively

Though survey respondents don’t indicate strong use of telehealth and remote monitoring, NEJM Catalyst Insights Council members discuss the ways they’re using these tools to monitor chronic disease, with good results.

Time Spent Engaging Directly with 16 Camden RESET Participants or Coordinating Care on Their Behalf

Leadership

“Putting All the Pieces Back”: Lessons from a Health Care–Led Jail Reentry Pilot

The Camden Coalition’s jail-based reentry program illuminated the necessity and challenges of engaging people with complex health and social needs and helping to transform the systems that serve them.

Top challenges facing chronic disease management care - insufficient time and care coordination

Care Redesign

Care Redesign Survey: To Improve Chronic Disease Care, Change the Payment Model

Many health care organizations are reasonably effective in treating chronic diseases, but they are limited from doing better by fee-for-service payment, which remains the predominant payment model in the United States. This report serves as a snapshot in time, showing the intent of health care providers to be proactive in treating chronic disease, but limitations in their ability to address population health.

End of Life EOL Palliative Care in the ED for Patients with Advanced Cancer - Process Map - MD Anderson Cancer Center

Care Redesign

Patient-Centered Care at the End of Life in the ED

How MD Anderson Cancer Center is improving end-of-life care in an unlikely place: the emergency department.

McKee01_pullquote - the need for coordinated care IPUs for Parkinson's disease

Care Redesign

Creating “One-Stop Shop” Care for Parkinson’s

Integrated Practice Units (IPUs) can revolutionize the care of specialty disease conditions, and Parkinson’s disease is a good place to start.

Good Shepherd culturally competent hospice care home visit to the widow of a recently deceased patient

Care Redesign

Strangers No More: Culturally Competent Add-On Programs for Diverse Seniors

Creating specialized culturally competent programs to improve patient satisfaction and address the unique health care needs of older immigrants.

Direct-to-Consumer Telemedicine Is the Biggest Coming Threat to Traditional Health Care Organizations

New Marketplace

Survey Snapshot: Mega-Mergers and Telemedicine Accelerate Convenient Care Growth

NEJM Catalyst Insights Council members detail how providers are looking to direct-to-consumer telemedicine and partnerships to meet the differing needs of their patient populations.

Kimberly Dennis and David Newton head shots - SunCloud Mental Health Services

Care Redesign

Addressing the Lack of Continuity of Care in Mental Health Services

Co-founders of an integrative outpatient treatment center for mental health and addiction discuss the problematic lack of continuity of care between inpatient and outpatient and physical and mental health services.

Miller03_pullquote social determinants whole-person

Leadership

How a State Advances Whole-Person Health Care

Pennsylvania addresses social determinants of health by bringing together managed care and social services organizations to expand access to vital resources.

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