A resource for population health leaders
Population health leaders struggle to find scalable management approaches that improve chronic disease outcomes while also managing utilization, so we studied chronic disease management (CDM) programs across the country and developed three recommendations for building scalable and effective CDM programs:
- Find modifiable patient risk factors rather than segmenting programs by disease
- Anchor consistent, long-term services in ambulatory care and invest in upstream services that drive longitudinal engagement
- Set clear pathways to specialists; PCPs don’t always know when patients can be managed in primary care or when they should be referred to specialty care
For each of these recommendations, we gathered proven tactics from leading organizations across the country. Please submit your information to the right to download an excerpt of this research report.