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Early intervention the missing link3/11/2023 ![]() Office-based CDM workers can potentially improve quality, enhance primary care physician satisfaction and productivity, promote self-management strategies, and reduce or control long-term costs related to poor patient outcomes, but their actual impact should be assessed at multiple levels. ![]() California’s well-established Comprehensive Perinatal Services Program (CPSP) is a good example of a payment mechanism that supports health education and case menagement services through payments to physician employers. A practical way to pay for and target CDM activities is to reimburse physicians for units of service delivered by their CDM workers. Office-based CDM workers can offer self-management and case management services for these patients and be the missing link that connects patients, families, and physicians with CDM services available through health plans or in the community. It is possible to achieve these multiple objectives by allocating dedicated health care assistants to work directly with patients who have chronic diseases at the point of care. We need a CDM strategy that improves quality, supports primary care physicians and patients, and is applicable in a diverse range of clinical settings. office practice issues: office redesign/practice redesignĪ crisis in primary care and chronic disease management (CDM) is looming.CDM workers can potentially improve quality while reducing costs for preventable hospitalizations and emergency department visits, but evaluation at multiple levels is recommended. Care provided by CDM workers should be standardized, and training requirements should be sufficiently flexible to ensure wide dissemination. CDM workers should be supported financially by Medicare, Medicaid, and commercial health plans through reimbursements to physicians for units of service, analogous to California’s Comprehensive Perinatal Services Program. CDM workers can provide the missing link by connecting patients, primary care physicans, and CDM services sponsored by health plans or in the community. Office-based chronic disease management (CDM) workers can achieve these objectives by offering self-management support, maintaining disease registries, and monitoring compliance from the point of care. Bold steps are necessary to improve quality of care for patients with chronic diseases and increase satisfaction of both primary care physicians and patients.
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