title: Using data to design systems of care adults with chronic illness.
abstract: Increased Medicare risk contracts led to rising concern with readmission rates among the senior population with chronic illness at Carondelet Health Network. Using readily available data, Carondelet providers and administrators created intervention and evaluation strategies to redesign chronic care services to reduce increased readmissions. The strategies showed health plans can develop such strategies without waiting for sophisticated information systems to be put in place.
authors.affiliation: Carondelet Health Network, Tucson, AZ, USA.
authors.forename: G S
authors.initials: GS
authors.lastname: Lamb
authors.forename: V
authors.initials: V
authors.lastname: Mahn
authors.forename: R
authors.initials: R
authors.lastname: Dahl
mesh_terms: D000328:Adult; D001130:Arizona / Q000453:epidemiology; D002204:Capitation Fee; D002908:Chronic Disease / Q000191:economics / Q000453:epidemiology / Q000628:therapy*; D003362:Cost-Benefit Analysis; D003625:Data Collection; D006801:Humans; D008329:Managed Care Programs / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D016347:Medical Records Systems, Computerized; D006278:Medicare / Q000458:organization & administration / Q000592:standards; D010359:Patient Readmission; D018802:Patient-Centered Care / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D016730:Program Development; D012308:Risk Management; D017749:Total Quality Management; D014481:United States / Q000453:epidemiology