How these health systems are transforming chronic disease care

Physicians and health systems across the country continue to face the growing challenge of preventing and managing chronic diseases. This intensifies the need to create innovative approaches to care. With conditions such as type 2 diabetes, heart disease and hypertension on the rise, health systems and the physicians who deliver care are navigating the changing terrain to address these complex health concerns.

Here is a list of how members of the AMA Health System Program—which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine—are stepping up to the plate to improve chronic disease management.

1. Bayhealth focuses on social needs

   A pilot program centered on Bayhealth’s cardiovascular service line and testing a social drivers of health focused approach for patients with heart failure helped lower readmission rates for these patients by a whopping 67%. Learn more about the effort at this Delaware health system.

2. Geisinger offers culinary medicine classes

   Whether it is to help patients maintain their heart health, regulate blood-glucose levels or sustain lasting energy on busy days, the cornerstone lies in adopting a nutritious and well-balanced diet. But if a patient is not familiar with healthy cooking, how do they know where to begin? This is something that the Geisinger health system has set out to change with its culinary medicine cooking classes.

3. Henry Ford tailors the EHR to boost diabetes prevention

   Nearly 100 million U.S. adults have prediabetes, and among those with the condition, just 19% find out they have this condition from a physician or other health professional. Physician leaders at Henry Ford Health decided to tackle these troubling statistics by implementing functionalities within their certified EHR platform to screen, test and refer patients with prediabetes.

4. Marshfield embraces hospital care at home

   The Marshfield Clinic Health System is located in central Wisconsin and offers services to an area of about 45,000 square miles. In those rural parts of Wisconsin and northern Michigan, patients can be forced to spend hours in transport trying to reach the nearest hospital or clinic. But with hospital-at-home care, readmissions and emergency departments visits for patients with chronic conditions can be prevented.

5. Ochsner offers a digitally enabled program

   If one were to design a health care program that improves patient outcomes, saves money and has high satisfaction ratings from both patients and physicians, it would probably look a lot like Ochsner Health’s Hypertension Digital Medicine service. The digitally enabled chronic disease-management program was designed to address the high rates of uncontrolled hypertension in Ochsner’s home state of Louisiana. Now it’s being used as a recruitment tool for primary care physicians. Learn why.

6. The Permanente Medical Group focuses on prevention

   Kaiser Permanente members living in Northern California were 30% less likely to die of heart disease or stroke than if the patient was a nonmember, according to Maria Ansari, MD, CEO of The Permanente Medical Group and the Mid-Atlantic Permanente Medical Group. And those outcomes weren’t because of the cardiologists. Find out why it starts with the basics in primary care.

7. Privia monitors new mothers’ blood pressure remotely

   During the fourth trimester, remote patient monitoring could help new mothers monitor their blood pressure to watch out for hypertension or postpartum preeclampsia, which are among the leading causes of postpartum maternal mortality. Find out how Privia uses “Femtech” to improve maternal outcomes after birth.

8. Saint Peter’s focuses on culturally appropriate care

   It isn’t easy to serve as the health care advocate for a population nearing 6 million people, but for endocrinologist Meena S. Murthy, MD, it is her calling. For more than 40 years, Dr. Murthy has been working to provide early detection of type 2 diabetes and cardiovascular disease in patients living in New Brunswick, New Jersey, focusing on culturally appropriate care and support for underserved populations, including patients of South Asian descent.

9. Sanford Health uses telehealth to reach patients with diabetes

   To achieve parity on virtual health, it is essential to demonstrate its value, says a North Dakota endocrinologist who uses a variety of methods to reach patients hundreds of miles away. For Sanford Health’s David Newman, MD, virtual technology has been a lifesaver in treating the unique patient population he serves in North Dakota and other areas. And it has made diabetes care so much easier.

AMA MAP™ Hypertension is an evidence-based quality improvement program that provides a clear path to significant, sustained improvements in BP control. With the AMA MAP program, health care organizations can increase BP-control rates quickly.

Additionally, the AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies.