Managing Patients with Multiple Chronic Conditions

Chronic diseases affect more than half of our patients, many with two or more chronic illnesses. In 2000, an estimated 125 million people had chronic conditions, with 48% having more than one condition. By 2020, those numbers are expected to grow to 157 million, with 81 million having more than one condition. Research has shown that a vast majority of these patients are not receiving the care they need.

Awareness of the growing prevalence of people with chronic conditions is not enough. We need to change the way health care is delivered to meet the common problems these patients face as they seek care to maintain their health and quality of life.

Best Practices in Managing Patients with Multiple Chronic Conditions
Best Practices in Managing Patients with Multiple Chronic Conditions (MPMCC) is a research project designed to bring together insights and resources to help healthcare providers improve care for patients with multiple chronic conditions. The objective is to develop a foundational framework and care process blue print relevant to clinical and operational models of organized systems of care, which will lead to improved patient outcomes including:

Early identification of patients at risk for chronic disease
Reduction in mortality and morbidity
Improved medication adherence and compliance
Improved continuity of care across care transitions
Increased efficiency and reduction in unnecessary or wasteful service and resources
Improved patient activation and self-management

During the yearlong learning collaborative, a “Best Practices” framework for managing patients with multiple chronic conditions will be developed and tested. The optimal chronic care framework will assist organizations in building the care coordination functions that are central to provider entities that will be held accountable for comprehensive healthcare services under the new health care reform legislation.

Participating project teams will be able to regularly network with peers, participate in bi-monthly conference calls on relevant project topics, attend two in-person meetings, and have timely access to industry experts. The learning collaborative will commence in June 2011 and concluded in June 2012.

Multiple Chronic Conditions Learning Collaborative Members Only

If you have questions or need further information, contact Danielle Flowers at dflowers@amga.org or at (703) 838-0033, ext. 347.

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