Implementation of a Population Health Chronic Disease Management Program

A pilot program was created by the network's primary care leadership team at Massachusetts General Hospital. They hired and allocated 4 population health coordinators (PHCs) as part of a pilot project to centralize population health management efforts to improve quality of care for chronic disease management. The network did not have sufficient resources to implement a PHC in all of the 18 network practices. So the program's team invited practice leaders to participate and the PHCs were allocated by program's leadership team based on a variety of factors including responses from the practice leader, baseline quality scores, size of the practice, nature of the practice (health center vs not), and location of the practice (on campus or community based). These decisions were made in a way that sought to equitably distribute available PHC resources within the practice network as a way to get network buy-in and maximize the impact of the program, both for practices with and without PHCs. In this study, the investigators evaluated quality of care process and outcome measures over the first six months of the chronic disease management program. The investigators hypothesized that practices assigned a central PHC would have greater performance increases in quality measures compared to practices that were not assigned a PHC.

Inclusion criteria

• Diabetes mellitus (type 1 or type 2), or cardiovascular disease (including coronary artery disease, peripheral vascular disease, and cerebrovascular disease), or hypertension
• Breast cancer: women 50-74 years of age
• Cervical cancer: women 21-64 years of age
• Colorectal cancer: men or women 52-75 years of age

Exclusion criteria

• Patients not connected with a specific network physician or practice
• Patients who switched between PHC and non-PHC practices during the follow-up period
• Breast: bilateral mastectomy
• Cervical: total hysterectomy Colorectal: total colectomy