Coordinated Care Management

August 08, 2012

Montefiore and Phytel Join to Help Control Chronic Disease

Phytel's registry-driven outreach and population health management tool has been chosen by Montefiore Medical Center, an integrated healthcare delivery system and the academic medical center for Albert Einstein College of Medicine, to identify and reconnect patients with their care team for preventive and chronic care.

The system is being used by the medical center's ambulatory care network, the Montefiore Medical Group, which includes about 350 employed physicians and provides primary and specialty care services at more than 20 locations to residents of the Bronx and Westchester County.

The medical group has been using Phytel's automation tools for six months to allow Montefiore to provide their doctors with a toolset to keep patients on track with their care plans.

"Montefiore is the major healthcare provider in the Bronx and one of only 32 Pioneer ACOs in the nation, and continuous outreach to our patients plays a vital role in maintaining their long-term health," said Don Raum, MD, regional medical director, Montefiore Medical Group, in a statement. "This tool helps us to improve the quality of preventive and chronic care by identifying patients with gaps in treatment and re-engaging them with their providers. Our aim is to solidify continuity of care and the doctor-patient relationship, and ultimately improve the long-term health outcomes of the entire population we serve."

Millions of people suffer from chronic diseases like asthma, epilepsy, heart disease, diabetes, Alzheimer’s and other diseases in the U.S. And chronic disease was estimated to eat up 83 percent of all healthcare spending, back in 2003. The average annual health care coverage cost for people with a chronic condition was $6,032 eight years ago, five times higher than for people without such a condition.

And as obesity, and all its related diseases, continues to rise in this country, that too will add to our chronic disease burden.

It’s clearly in everyone’s best interests to try to keep chronic diseases under control, and how better to do that than connecting patients with healthcare teams?

Edited by Rachel Ramsey

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