Developing a Poly-Chronic Care Network - An Engineered, Community-Wide Approach to Disease Management

Although much has been achieved in care coordination and accountable care, healthcare leaders need additional, game-changing innovations to deal with constraints in clinical resources, care capacity, and cost that have not yet been fully addressed. This need for innovation is especially great in the care of the chronically ill: the most costly, highest-risk segments of our populations.Filling this void, Developing a Poly-Chronic Care Network: An Engineered, Community-Wide Approach to Disease Management reconstructs and augments traditional chronic care delivery models. The proposed solution-the Poly-Chronic Care Network(c) (PCCN)-is a specific iteration of the Care Circle Network(c) (CCN) concept that creates a sustainable community-engaging response to the complexity, cost, and outcomes of chronic diseases. By dynamically engineering all the elements of a community's ",Capacity to Care", directly into short- and long-term patient care processes, the PCCN expands care capacity and physician ",reach",, and improves quality and outcomes, without increasing the total cost of care.The book describes the fundamental concepts, principles, and requirements for the PCCN and explains how this care model could augment and enhance other new business models, such as Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs). In addition to a detailed description of implementation steps and organizational structures, the text provides useful insights into technologies that can aid and enhance implementation, including home/virtual monitoring, social networking, and dynamic simulation. Importantly, the book includes both detailed examples and a flexible how-to guide for setting up a PCCN or other CCN, offering readers step-by-step guidelines and options for combining readily-available communal resources with simple technologies in the design of innovative care models for their communities.With this book in hand, readers can confidently pick and choose specific components to match their community's needs and capabilities, ",amending the blend", to account for the size, scale, scope, and population of the community and patients they wish to serve.