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Disease Management Programs for uninsured and underinsured, low-income patients with diabetes, asthma, and heart failure

jessievenegas Jessie Venegas — 10/01/2009

The Los Angeles County Department of Health Services has implemented disease management programs for uninsured and underinsured, low-income patients with diabetes, asthma, and heart failure who have historically not had access to this type of care and support. The program uses a proactive approach to identify and stratify the population into 3 groups based on their risk profile, with each group receiving services tailored to their needs. • The low-risk group: have a single, relatively straightforward chronic illness. • Medium-risk group: are individuals tend to be complex and/or have multiple chronic illnesses with a pattern of high resource use relative to their burden of illness. • The high-risk group: tend to have multiple chronic illnesses, such as heart failure, diabetes, asthma, and/or chronic obstructive pulmonary disease, along with multiple co-morbidities associated with these conditions The process of care has been restructured to improve coordination of services and to increase efficiency, with more than one-half of the patient contacts taking place over the phone or through remote monitoring. The program has reduced missed school days and emergency department (ED) and inpatient utilization for children with asthma and has improved glucose, lipid, and blood pressure control for patients with diabetes. Based on these successes, the program will be expanded to include adults with asthma and

Diabetes, Heart failure, Asthma, Fragility, pluripathology/polipathology and/or complex chronic diseases, All

Goals Prevention:
Promotes adecuate understanding levels on the community about the importance of prevention , Focuses on social inequalities
Goals Treatment:
Develop basic elements for an integrated health system , Provides support health policies to facilitate the planning and integration at locally and regionally , Strengthens cooperative local groups to provide integral services , Ensures the best quality of health services , It facilitates the management by processes , Emphasizes the care of pluri-pathological and fragile patients

None

Progress

UNITED STATES OF AMERICA

California

California

Los Angeles

Los Angeles, CA
Practices Map
 

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