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Coordinated Chronic Disease

Domain 3:  Healthcare Systems



Domain 3: Health system interventions to improve the effective delivery and use of clinical and other preventive services in order to prevent disease, detect diseases early, and reduce or eliminate risk factors and mitigate or manage complications. 

Health systems interventions improve the clinical environment to more effectively deliver quality preventive services and help Americans more effectively use and benefit from those services. The result: some chronic diseases and conditions will be avoided completely, and others will be detected early, or managed better to avert complications and progression and improve health outcomes. Health system and quality improvement changes such as electronic health records, systems to prompt clinicians and deliver feedback on performance, and requirements for reporting on outcomes such as control of high blood pressure and the proportion of the population up-to-date on chronic disease screenings can encourage providers and health plans to focus on preventive services. Effective outreach to consumers and reducing barriers to accessing these services is also key, as coverage alone will not ensure use of preventive services.

Examples of Activities

  • Delivery of high-quality screening for breast, cervical, and colorectal cancers that promotes high rates of appropriate use, including timely referral and follow-up.
  • Organized systems of care to deliver high-quality clinical and other preventive services (as recommended by the U.S. Preventive Services Task Force and the Community Guide):
    • Electronic health records with registry function, decision support, and electronic reminders; 
    • Team-based care; 
    • Population care across panel of patients; 
    • Systems to ensure adequate follow-up of abnormal screening tests, and timely treatment;
    • Patient-centered medical and dental home.
    • Health care information systems with automated physician prompts or patient reminder letters for screening and follow-up clinical counseling or referral.
    • Quality improvement of clinical care for cancer screening and control of A1C, blood pressure, BMI, and cholesterol.
    • Birthing hospitals using Baby Friendly Hospital Initiative policy recommendations and implementing "Ten Steps for Successful Breastfeeding in Hospitals.”
    • Delivery of smoking cessation services and treatments - including providing quitline coaching and cessation treatments as covered benefits.
    • Increase access to and use of clinical and preventive oral health services 
    • Provision of quality, accessible, and confidential family planning services, including contraceptive methods and services.