Medical Neighborhood Impact on Chronic Conditions

(Project Emerging in 2017)

What is the purpose?

Advancing results-based practices to improve alignment of clinical-community activity on chronic conditions.

What are the objectives?

  • Starting with diabetes and/or depression in 2017.
  • Build new accountable clinical-community partnerships.
  • Reduce variation by implementing best practices, such as:
    • Clinical protocols for chronic disease management
    • Care coordination
    • Quality measurement
    • Patient education and engagement
    • Payment innovation
  • Increase the number of patients with chronic conditions IN CONTROL based on regional health goals.