AMGA Diabetes Risk Model Development Project: A multi-site research and demonstration project to help medical groups identify high risk diabetes patients, and institute changes in care processes that produce better quality of life, improved clinical status, and lead to a decrease in unnecessary utilization of health care resources.

Twelve medical groups participated in the research phase of the study by contributing two consecutive years of data on a minimum of 411 diabetic patients. By measuring change over time of critical, predictive factors including health status, lab results and utilization patterns, the project was able to develop models to help physicians identify and manage high-risk patients in the office setting. These tools are now ready to be automated and tested in medical group demonstration sites.

Chronic Care Improvement Demonstration Project: This project will bring together medical groups who are dedicated to designing and testing systems of care that improve the quality of care and satisfaction of chronically ill patients with multiple medical conditions. The goal of the project is to develop and implement a chronic care model that promotes continuity of care, stabilizes medical conditions, and reduces adverse health outcomes, while reducing the cost of care.

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