An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions

Popul Health Manag. 2017 Feb;20(1):23-30. doi: 10.1089/pop.2016.0076. Epub 2016 Aug 26.


Although the health care reform movement has brought about positive changes, lingering inefficiencies and communication gaps continue to hamper system-wide progress toward achieving the overarching goal-higher quality health care and improved population health outcomes at a lower cost. The multiple interrelated barriers to improvement are most evident in care for the population of patients with multiple chronic conditions. During transitions of care, the lack of integration among various silos and inadequate communication among providers cause delays in delivering appropriate health care services to these vulnerable patients and their caregivers, diminishing positive health outcomes and driving costs ever higher. Long-entrenched acute care-focused treatment and reimbursement paradigms hamper more effective deployment of existing resources to improve the ongoing care of these patients. New models for care coordination during transitions, longitudinal high-risk care management, and unplanned acute episodic care have been conceived and piloted with promising results. Utilizing existing resources, Mobile Integrated Healthcare is an emerging model focused on closing these care gaps by means of a round-the-clock, technologically sophisticated, physician-led interprofessional team to manage care transitions and chronic care services on-site in patients' homes or workplaces.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Chronic Disease* / economics
  • Chronic Disease* / therapy
  • Cost Control
  • Delivery of Health Care, Integrated / economics
  • Delivery of Health Care, Integrated / standards*
  • Efficiency, Organizational
  • Health Care Costs
  • Health Care Reform
  • Health Services Accessibility
  • Humans
  • Patient Transfer
  • Quality Assurance, Health Care*
  • Quality Improvement
  • United States