Chronic illness management and population-based care

Acumentra Health has performed quality improvement work in the Medicare program since 1984, much of it focused on improving care for chronically ill populations, such as people with diabetes and heart failure. We have spearheaded diverse projects and initiatives to provide clinical teams with tools, methods, and strategies, several of which have gained national recognition.

Our publication Healthy Living with Heart Failure: A Patient’s Guide has been disseminated nationally and used in hospitals, clinics, and patient education programs throughout the United States.

The Care Model (Chronic Care Model) and collaboratives

Acumentra Health has conducted multiple collaborative projects to improve chronic care management through implementation of the Care Model (formertly the Chronic Care Model) developed by Dr. Ed Wagner and colleagues in the Robert Wood Johnson Foundation-sponsored Improving Chronic Illness Care (ICIC) program. Acumentra Health has ongoing direct relationships with Dr. Wagner and with ICIC, which includes our materials on its resource website.

• Acumentra Health was the primary sponsor for the two Oregon Diabetes Collaboratives, which helped a group of primary care practices improve several measures of care, applying a yearlong shared learning approach developed by the Institute for Healthcare Improvement.
• We also adapt the Care Model and collaborative approach to the needs of our customers.
  • We developed and presented a "skinny" version of the Care Model for the Oregon Rural Collaborative, which piloted distance learning approaches to teach chronic care approaches around the state.

In addition, we co-led the Oregon GAP Heart Failure collaborative, sponsored by the American College of Cardiology, to improve communication among clinicians and education and follow-up with patients.