The U.S. chronic illness burden is increasing and is felt more strongly in minority and low-income populations: in 2005, 133 million Americans had at least one chronic condition. Prevention and management of chronic disease are best performed by multidisciplinary teams in primary care and public health. However, the future health care workforce is not projected to include an appropriate mix of personnel capable of staffing such teams. To prepare for the growing chronic disease burden, a larger interdisciplinary primary care workforce is needed, and payment for primary care should reward practices that incorporate multidisciplinary teams. [Health Affairs 28, no. 1 (2009): 64-74; 10.1377/hlthaff .28.1.64] I n 2 0 0 5 , 13 3 m i ll i o n a m e r i c an s w e r e l i v i n g with at least one chronic condition. In 2020, this number is expected to grow to 157 million. In 2005, sixty-three million people had multiple chronic illnesses, and that number will reach eighty-one million in 2020. 1 Not surprisingly, the proportion of the population diagnosed with chronic conditions increases with age (Exhibit 1). More worrisome is the striking gap between the high prevalence of chronic conditions among people who are below the federal poverty level compared with the average prevalence in the general population. The cost burden of chronic illness-currently 78 percent of total health spending-will increase markedly by 2023 (Exhibit 2). The number of people with diabetes is expected to double in the next twenty-five years, from twentyfour million to forty-eight million. By 2023, the number of people with chronic mental disorders may increase from thirty million to forty-seven million. Similar increases are forecast for virtually every common chronic condition. 6 4 J a n u a r y / F e b r u a r y 2 0 0 9 R e o r g a n i z i n g C a r e n Reasons for increased prevalence. Reasons for the increased prevalence of chronic conditions are multifactorial-including an aging population plus a rise in disease-specific risk factors such as obesity. A comparison of chronic disease prevalence in the United States and in ten European countries reveals a markedly lower prevalence in Europe of heart disease, hypertension, diabetes, obesity, and arthritis. This difference may be attributable to a healthier diet and lower poverty rates in Eu- 4 The population over age eighty-five, the group with the highest proportion of people with multiple chronic conditions, is projected to grow from five million in 2005 to twenty-one million in 2050, ensuring a major increase in the number of very-high-cost patients.n Four policy questions. These data raise both general societal issues and specific policy questions. In this paper we address four specific policy questions, with greatest emphasis placed on questions 2 and 3: (1) Can dramatic public health prevention slow down the rate of increase of chronic disease prevalence? (2) Should chronic care be delivered chiefly by specialist physicians, generalist physicians, or multidisciplinary teams...

PURPOSE Peer health coaches offer a potential model for extending the capacity of primary care practices to provide self-management support for patients with diabetes. We conducted a randomized controlled trial to test whether clinic-based peer health coaching, compared with usual care, improves glycemic control for low-income patients who have poorly controlled diabetes. METHODWe undertook a randomized controlled trial enrolling patients from 6 public health clinics in San Francisco. Twenty-three patients with a glycated hemoglobin (HbA 1C ) level of less than 8.5%, who completed a 36-hour health coach training class, acted as peer coaches. Patients from the same clinics with HbA 1C levels of 8.0% or more were recruited and randomized to receive health coaching (n = 148) or usual care (n = 151). The primary outcome was the difference in change in HbA 1C levels at 6 months. Secondary outcomes were proportion of patients with a decrease in HbA 1C level of 1.0% or more and proportion of patients with an HbA 1C level of less than 7.5% at 6 months. Data were analyzed using a linear mixed model with and without adjustment for differences in baseline variables.RESULTS At 6 months, HbA 1C levels had decreased by 1.07% in the coached group and 0.3% in the usual care group, a difference of 0.77% in favor of coaching (P = .01, adjusted). HbA 1C levels decreased 1.0% or more in 49.6% of coached patients vs 31.5% of usual care patients (P = .001, adjusted), and levels at 6 months were less than 7.5% for 22.0% of coached vs 14.9% of usual care patients (P = .04, adjusted).CONCLUSIONS Peer health coaching signifi cantly improved diabetes control in this group of low-income primary care patients. Ann Fam Med 2013;11:137-144. doi:10.1370/afm.1443. INTRODUCTIONP rimary care faces serious challenges in the face of the growing demand for diabetes care. Primary care physicians are in short supply and need more time to care for patients with highly complex conditions whose costs are destabilizing US health care.1 Current numbers of nurse practitioners and physician assistants are not suffi cient to provide access to the increasing demand for primary care.1,2 Registered nurses and pharmacists, who are capable of managing a large proportion of patients with diabetes, are too costly for many primary care practices. The time of medical assistants is often consumed by managing patient fl ow and assisting clinicians to get through the day. 3 In sum, many primary care practices have no one available to provide the time-consuming counseling and teaching of self-management skills that have been shown to improve diabetes outcomes. 4 To address this need, several models have been developed to provide support for patient self-management from lay workers with minimal 138 PEER HE A LT H COACHING A ND G LYC EMIC CON T ROLtraining, including community health workers, lay peer educators, and peer coaches. Community health workers are from the community of the patients they assist but do not necessarily have the same disease as the patient. ...

Background Colorectal cancer (CRC) screening remains underused, especially in safety-net systems. The objective of this study was to determine the effectiveness, costs, and cost-effectiveness of organized outreach using fecal immunochemical tests (FITs) compared with usual care. Methods Patients age 50–75 years eligible for CRC screening from eight participating primary care safety-net clinics were randomly assigned to outreach intervention with usual care vs usual care alone. The intervention included a mailed postcard and call, followed by a mailed FIT kit, and a reminder phone call if the FIT kit was not returned. The primary outcome was screening participation at 1 year and a microcosting analysis of the outreach activities with embedded long-term cost-effectiveness of outreach. All statistical tests were two-sided. Results A total of 5386 patients were randomly assigned to the intervention group and 5434 to usual care. FIT screening was statistically significantly higher in the intervention group than in the control group (57.9% vs 37.4%, P < .001; difference = 20.5%, 95% confidence interval = 18.6% to 22.4%). In the intervention group, FIT completion rate was higher in patients who had previously completed a FIT vs those who had not (71.9% vs 35.7%, P < .001). There was evidence of effect modification of the intervention by language, and clinic. Outreach cost approximately $23 per patient and $112 per additional patient screened. Projecting long-term outcomes, outreach was estimated to cost $9200 per quality-adjusted life-year gained vs usual care. Conclusion Population-based management with organized FIT outreach statistically significantly increased CRC screening and was cost-effective in a safety-net system. The sustainability of the program and any impact of economies of scale remain to be determined.

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Evidence-based system approaches to improving BP control can be implemented in safety-net settings and could play a pivotal role in achieving improved population BP control and reducing hypertension disparities.

Background: Lack of concordance between medications listed in the medical record and taken by the patient contributes to poor outcomes. We sought to determine whether patients who received health coaching by medical assistants improved their medication concordance and adherence.Methods: This was a nonblinded, randomized, controlled, pragmatic intervention trial. English-or Spanish-speaking patients, age 18 to 75 years, with poorly controlled type 2 diabetes, hypertension, and/or hyperlipidemia were enrolled from 2 urban safety net clinics and randomized to receive 12 months of health coaching versus usual care.Results: Outcomes included concordance between medications documented in the medical record and those reported by the patient and adherence based on the patient-reported number of days (of the last 7) on which patient took all prescribed medications. The proportion of medications completely concordant increased in the coached group versus the usual care group (difference in change, 10%; P ‫؍‬ .05). The proportion of medications listed in the chart but not taken significantly decreased in the coached group compared with the usual care group (difference in change, 17%; P ‫؍‬ .013). The mean number of adherent days increased in the coached but not in the usual care group (difference in change, 1.08; P < .001).

Cultural values and beliefs about the primary care physician bolster the myth of the lone physician: a competent professional who is esteemed by colleagues and patients for his or her willingness to sacrifi ce self, accept complete responsibility for care, maintain continuity and accessibility, and assume the role of lone decision maker in clinical care. Yet the reality of current primary care models is often fragmented, impersonal care for patients and isolation and burnout for many primary care physicians. An alternative to the mythological lone physician would require a paradigm shift that places the primary care physician within the context of a highly functioning health care team. This new mythology better fulfi lls the collaborative, interprofessional, patient-centered needs of new models of care, and might help to ensure that the work of primary care physicians remains compassionate, gratifying, and meaningful.

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