title: Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities.
abstract: Population care approaches for diabetes have the potential to improve the quality of care and decrease diabetes-related mortality and morbidity. Population care strategies are particularly relevant as accountable care organizations (ACOs), patient-centered medical homes (PCMH), and integrated delivery systems are increasingly focused on managing chronic disease care at the health system level. This review outlines the key elements of population care approaches for diabetes in the current health care environment.
  
  
  
  Population care approaches proactively identify diabetes patients through disease registries and electronic health record data and utilize multidisciplinary care teams, personalized provider feedback, and decision support tools to target and care for patients at risk for poor outcomes. Existing evidence suggests that these strategies can improve care outcomes and potentially ameliorate existing race/ethnic disparities in health care. However, such strategies may be less effective for patients who are disengaged from the health care system. As population care for diabetes continues to evolve, future initiatives should consider ways to tailor population care to meet individual patient needs, while leveraging improvements in clinical information systems and care integration to optimally manage and prevent diabetes in the future.
authors.affiliation: Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA. Julie.A.Schmittdiel@kp.org.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Schmittdiel
authors.affiliation: Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
authors.forename: Anjali
authors.initials: A
authors.lastname: Gopalan
authors.affiliation: Kaiser Permanente Northern California Oakland Medical Center, Oakland, CA, USA.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Lin
authors.affiliation: Kaiser Permanente Northern California Oakland Medical Center, Oakland, CA, USA.
authors.forename: Somalee
authors.initials: S
authors.lastname: Banerjee
authors.affiliation: Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.|University of California at Berkeley School of Public Health, Berkeley, CA, USA.
authors.forename: Christopher V
authors.initials: CV
authors.lastname: Chau
authors.affiliation: Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
authors.forename: Alyce S
authors.initials: AS
authors.lastname: Adams
mesh_terms: D020000:Decision Support Systems, Clinical; D003695:Delivery of Health Care; D003920:Diabetes Mellitus / Q000208:ethnology / Q000628:therapy*; D054625:Healthcare Disparities; D006801:Humans; D058996:Quality Improvement
keywords: Chronic illness care; Diabetes; Disparities; Population care; Population health; Quality improvement