Innovative Information Technology-Powered Population Health Care Management Improves Outcomes and Reduces Hospital Readmissions and Emergency Department Visits.

BACKGROUND: Patients with chronic conditions are often the most frequent users of health care. Moreover, adapting to developments in one's illness, understanding how to self-manage a chronic illness, and sharing information between primary care and specialty providers, can be a full-time job for someone with a chronic illness. In response to these challenges, Christiana Care Health System (Wilmington, Delaware) developed Care Link, an information technology (IT)-enhanced care management support to enable populations of patients to achieve better clinical outcomes at lower cost. METHODS: In 2012 Christiana Care received a grant to design a generalizable, scalable, and replicable IT-driven care model that would integrate disparate clinical and registry data generated from routine care to support longitudinal care management for patients with ischemic heart disease. The single-disease care management program was expanded beginning in mid-2015 to serve risk-based models for many diseases and chronic conditions. RESULTS: More than 8,600 patients in several surgical and medical populations, including joint replacement, cervical spine surgery, and congestive heart failure, have been supported by Care Link. For example, preoperative assessment of patients with elective joint replacement to predict post-acute care needs led to an increase in the volume of patients discharged to home with self-care or with home health care by 30%-from 61% to 80%. CONCLUSION: Care Link IT functions can be replicated to address the unique longitudinal care needs of any population. Care Link's next steps are to continue to increase the number of patients served throughout the region and to expand the scope of care management programming.

A proposal to address the curriculum for the M-4 medical student.

The unstructured and elective nature of the fourth-year medical student (M4) medical school curriculum has been recognized by medical educators as an area of concern. Few accepted guidelines exist for the M4 curriculum, and students exercise significant discretion over their experience. The Family Medicine Curriculum Resource Project post-clerkship resource was developed by the Society of Teachers of Family Medicine under contract from the Health Resources and Service Agency to support medical educators in the development of curricula and assessment of student needs for the M4 year of medical school. The post-clerkship resource defines competencies for graduation and contains educational resources as well as recommendations for faculty development and student evaluation in the M4 year.

The Future of Family Medicine: a collaborative project of the family medicine community.

BACKGROUND: Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. METHODS: A national research study was conducted by independent research firms. Interviews and focus groups identified key issues for diverse constituencies, including patients, payers, residents, students, family physicians, and other clinicians. Subsequently, interviews were conducted with nationally representative samples of 9 key constituencies. Based in part on these data, 5 task forces addressed key issues to meet the project goal. A Project Leadership Committee synthesized the task force reports into the report presented here. RESULTS: The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health and health care of the nation. The proposed New Model of practice has the following characteristics: a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance. A unified communications strategy will be developed to promote the New Model of family medicine to multiple audiences. The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine's basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement. Ultimately, systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices. CONCLUSIONS: The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans.

Well child and preventive care.

In summary, primary care providers play an extremely important role in providing preventive care. In the USA, the primary care physician is the major deliverer of well childcare. Numerous resources exist as a guide to the recommended content of health supervision visits. Despite the overall improvement in the health of children, areas that continue to challenge us, include childhood poverty and persistent health disparities among different ethnic groups. Although, solutions to these problems may well lie with political and social organizations that take a population-based approach to health care, each visit into the primary care provider's office provides an opportunity to review urgent concerns, update immunization status, address developmental and behavioral concerns and promote healthy lifestyles.

Preventive care for the menopausal woman.

In summary, menopause represents a stage in a woman's life for the primary care physician to have an important impact on health [43]. Decision-making must weigh individual risk factors for health disease, osteoporosis and breast cancer. Hormone replacement therapy remains an important issue for the postmenopausal woman [44]. More evidence is needed to define the specific health benefits and risks of HRT, particularly as it relates to the prevention of CHD. A patient centered approach using a shared decision making model is most likely to result in improved patient satisfaction and desired health outcome.