How We Plan to Achieve This Goal
CHCF's Better Chronic Disease Care program focuses on improving clinical outcomes and quality of life for Californians with chronic conditions through the pursuit of these two objectives:
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Effective Providers. This objective works to expand the number of providers who effectively care for patients with chronic conditions through engagement of patients and families and use of technology. Projects that support this objective include acceleration of the use of chronic disease registries and electronic health records to improve care in the safety net, promotion of data-driven quality improvement initiatives, and redesign of small practices using health information technology. Read details about this objective's initiatives, accomplishments, and next steps.
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Appropriate Care Toward the End of Life. This objective promotes care toward the end of life that is consistent with patients' wishes. Projects that support this objective include the development of palliative care programs in public hospitals and the encouragement of adoption of POLST (a physician order co-signed by the patient that provides clear directions for care). Read details about this objective's initiatives, accomplishments, and next steps.
Why We Focus on This Goal
In California, 38% of the population has at least one chronic illness and many suffer from several chronic conditions. These numbers are expected to rise sharply over the next decade, as is the cost of treatment, which already accounts for the majority of health care spending in the state.
"Chronic conditions such as diabetes and heart disease are major causes of illness, disability, and death in California as in the United States," says Sophia Chang, M.D., M.P.H., director of CHCF's Better Chronic Disease Care program. "A lot is known about how to prevent chronic disease and delay or avoid many related complications. Despite that knowledge, research shows that chronically ill patients get recommended standards of care only about half the time."
For details, see a snapshot of statistics (PDF) for chronic disease prevalence by race, self-reported health status for Californians with chronic disease, preventable hospitalizations by chronic condition, and more.
What We Are Working Toward
California will move from reactive, episodic chronic disease care delivery to care that is proactive and systematic. Providers will continually redesign their practices to provide care more efficiently. They will have timely electronic information to make better decisions and develop treatment plans with patients and families. Health care professionals will acknowledge and support the major decision-making role that patients and families have in managing their chronic conditions and will demonstrate improved clinical outcomes. Patients with advanced chronic disease will receive care consistent with their wishes, have more options for palliative care, and as a result, there will be less inappropriate health care spending at the end of life.
Principles That Guide Us
- Engage and encourage providers to make necessary changes to care practices.
- Promote appropriate use of technology as a key enabler to improve practice, while maintaining privacy safeguards.
- Emphasize partnership with patients and families with attention to needs, preferences, and cultural appropriateness of care.
- Spread evidence-based practices in existing health care settings.
For More Information
See highlights of this program's publications and projects and the list of staff.