The Need

The need for patients to be aware of and involved in managing their health is critical, especially for those living with a chronic disease. Living well in spite of diabetes, cardiovascular disease, depression, asthma or other chronic diseases require regular monitoring, active management, and a team approach to health.

The 2001 Institute of Medicine (IOM) report, “Crossing the Quality Chasm” described in great detail the gap between the actual state of healthcare in the United States and the ideal. Disparities or gaps in a patient’s health and a patient’s knowledge about their health in general have led to patients experiencing serious health conditions and even costly emergency room visits.

“Chronic conditions are now the leading cause of illness, disability and death; they affect almost half of the U.S. population and account for the majority of healthcare expenditures” (Hoffman et al 1996; The Robert Wood Johnson Foundation 1996)

Our Actions

Using a patient-centered model of care referred to as the Care Model, community health centers focus on how:

• Providers such as doctors, dentists, social workers, and nurses deliver care;
• Patients understand and participate in managing their own care; and
• Communities learn to strengthen the provider-patient partnership.

The Care Model empowers patients to establish their own goals in managing their health in addition to taking the realistic steps necessary to achieve these goals. In this model of care, medical providers and health center staff serve as a support system for patients, working with community organizations to identify resources to assist patients with meeting their goals.

In an effort to support the Care Model across all of Maine’s community health centers, MPCA created the Maine Chronic Illness Collaborative (MCIC). The MCIC is a state-based collaborative authorized by the federal government and focused on the needs specific to Maine residents and our health centers.

The benefits of our approach are:

• Improved patient outcomes/results
• Improved documentation/tracking of patient outcomes
• Improved readiness to undertake Health Information Technology efforts such as Electronic Medical Records
• Networked decision support that is especially valuable for rural practices
• Reporting assistance and documentation support

Outcomes & Achievements

In the report “Access Granted,” released in August by the National Association of Community Health Centers and the Robert Graham Center, researchers found that medical expenses for Community Health Center patients are 41 percent lower compared to patients seen elsewhere. The lower costs are attributed to these health centers’ patient-centered approach to care and the overall high quality of care offered, both of which improve patient outcomes and reduce the reliance on overburdened emergency rooms.

In addition, community health centers were the first in Maine to adopt and apply the Care Model. Now, all of Maine’s Community Health Centers are on track to have incorporated this patient-centered approach to high quality care within their practices by 2008. As a result, Maine CHCs have been recognized both at the state and national level for the quality of care offered to patients living with chronic conditions.