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

Descripción de la práctica:
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

Otra información de interés:
None

Editor: