Managing Patients with Multiple Chronic Conditions

Best Practices in 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.

Case Studies
AMGA partnered with Merck Sharp & Dohme Corp. to develop Best Practices in Managing Patients with Managing Patients with Multiple Chronic Conditions Compendium. The Compendium includes case studies from medical groups, independent practice associations, academic practices, and integrated delivery systems that have led to improvement in patients with more than one chronic condition.

Learning Collaborative
Best Practices Learning Collaborative Best Practices in Managing Patients with Multiple Chronic Conditions (MPMCC) was a research project designed to bring together insights and resources to help healthcare providers improve care for patients with multiple chronic conditions. The objective was 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

Ten medical groups were awarded $10,000 grants to support their initiatives; an additional 12 organizations were supported with travel stipends to attend the collaborative meetings. Participating project teams were able to regularly network with peers, participated in bi-monthly conference calls on relevant project topics, attended two in-person meetings, and had timely access to industry experts. The learning collaborative commenced in June 2011 and concluded in November 2012.

If you have questions or need further information, contact Danielle Casanova at 703.838.0033 ext. 347.