title: The development and implementation of the Chronic Care Management Programme in Counties Manukau.
abstract: OBJECTIVE
  To develop an effective and efficient process for the seamless delivery of care for targeted patients with specific chronic diseases. To reduce inexplicable variation and maximise use of available resources by implementing evidence-based care processes. To develop a programme that is acceptable and applicable to the Counties Manukau region.
  
  
  METHODS
  A model for the management of people with chronic diseases was developed. Model components and potential interventions were piloted. For each disease project, a return on investment was calculated and external evaluation was undertaken. The initial model was subsequently modified and individual disease projects aligned to it.
  
  
  RESULTS
  The final Chronic Care Management model, agreed in September 2001, described a single common process. Key components were the targeting of high risk patients, organisation of cost effective interventions into a system of care, and an integrated care server acting as a data warehouse with a rules engine, providing flags and reminders. Return on investment analysis suggested potential savings for each disease component from $277 to $980 per person per annum.
  
  
  CONCLUSIONS
  For selected chronic diseases, introduction of an integrated chronic care management programme, based on internationally accepted best practice processes and interventions can make significant savings, reducing morbidity and improving the efficiency of health delivery in the Counties Manukau region.
authors.affiliation: Integrated Care Unit, Counties Manukau District Health Board, Auckland, New Zealand. JWellingham@CMDBH.org.nz
authors.forename: John
authors.initials: J
authors.lastname: Wellingham
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Tracey
authors.forename: Harold
authors.initials: H
authors.lastname: Rea
authors.forename: Barry
authors.initials: B
authors.lastname: Gribben
mesh_terms: D002908:Chronic Disease; D003363:Cost Control; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D003920:Diabetes Mellitus / Q000191:economics / Q000628:therapy*; D019468:Disease Management; D017048:Health Care Costs / Q000706:statistics & numerical data; D006333:Heart Failure / Q000191:economics / Q000628:therapy*; D006801:Humans; D008134:Long-Term Care / Q000458:organization & administration*; D009520:New Zealand; D010865:Pilot Projects; D011320:Primary Health Care / Q000458:organization & administration*; D016730:Program Development; D029424:Pulmonary Disease, Chronic Obstructive / Q000191:economics / Q000628:therapy*