Initiative Tackles Chronic Disease Management

As part of the Academy's ongoing commitment to help family physicians provide comprehensive care to patients with chronic disease, AAFP is participating in an Institute for Healthcare Improvement initiative dubbed New Health Partnerships, or NHP.

The recently launched initiative was designed to raise awareness of collaborative self-management support, a system of care that promotes patient and provider synergy in the treatment of chronic disease.

Nearly 20 organizations, including the American Academy of Pediatrics, the National Committee for Quality Assurance, the National Quality Forum and the Robert Wood Johnson Foundation, also are actively supporting New Health Partnerships.

For its part, the AAFP Board of Directors appointed FP Bertha Safford, M.D., of Ferndale, Wash., to represent the Academy in the initiative. Safford, a former member of the AAFP's Commission on Health Care Services and Commission on Quality and Scope of Practice, champions the chronic care model -- which includes collaborative self-management support -- in her own practice.

Before attending the kick-off meeting with the initiative's supporters on March 6 in Washington, D.C., Safford quizzed many of the 40-plus family physicians she works with about what could be done to ease the strain of treating patients with diabetes. "The most common theme I heard was 'help us with our noncompliant patients,'" said Safford.

"Experience has shown that if you do everything in the planned-care model but don't include self management, you're only going to get so far. Patient self-management is the critical piece, and this initiative gives us tools to incorporate true patient self-management -- such as patient goal-setting -- into a typical busy family medicine practice. That's one of the reasons it's so exciting," said Safford.

"Self-management support is the most important intervention physicians can do to improve patient outcomes," said FP David Swieskowski, M.D., M.B.A., vice president of Mercy Clinics Inc. in Des Moines, Iowa. "The New Health Partnerships pilot collaborative provided both the knowledge and the motivation to implement (self-management support) in Mercy Clinics," he added.

Swieskowski's experience as a participant in NHP's initial nine-month pilot project, which ran from October 2003 to April 2004, is detailed in an article on the NHP Web site.

Safford stressed that the initiative is more than just a Web site. "What I learned at the kick-off meeting is that the concept is partnering with the patients to set mutual goals; the Web site is a place where you can go for resources and tools," she said.

Part of the Academy's role in supporting the initiative will be to

AAFP has created an e-mail discussion list (Members Only) to help facilitate that flow of information. Members who sign up to participate in the discussion list will automatically receive updates about New Health Partnerships by e-mail. The discussion list also features a bulletin board option that allows FPs to post and read messages from other list members.

The chronic care model is a focal point of several other AAFP educational programs, as well. Opportunities are available through the Practice Enhancement Forum, the Measuring, Evaluating, and Translating Research Into Care, or METRIC, program and the AAFP 2007 Annual Clinical Focus on management of chronic illness. (PDF file: 4 pages / 232 KB. More about PDFs.)