The SF-12 survey provided additional predictive ability for future hospitalizations and mortality. Such predictive ability might facilitate preemptive interventions that would change the course of disease in this segment of the population. However, nonresponder bias may limit the utility of mailed SF-12 surveys in certain populations.

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.

Objective. To determine how the addition of generalist care managers and collaborative information technology to an ambulatory team affects the care of patients with diabetes. Study Setting. Multiple ambulatory clinics within Intermountain Health Care (IHC), a large integrated delivery network. Study Design. A retrospective cohort study comparing diabetic patients treated by generalist care managers with matched controls was completed. Exposure patients had one or more contacts with a care manager; controls were matched on utilization, demographics, testing, and baseline glucose control. Using role-specific information technology to support their efforts, care managers assessed patients' readiness for change, followed guidelines, and educated and motivated patients. Data Collection. Patient data collected as part of an electronic patient record were combined with care manager-created databases to assess timely testing of glycosylated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels and changes in LDL and HbA1c levels. Principal Findings. In a multivariable model, the odds of being overdue for testing for HbA1c decreased by 21 percent in the exposure group (n 5 1,185) versus the control group (n 5 4,740). The odds of being tested when overdue for HbA1c or LDL increased by 49 and 26 percent, respectively, and the odds of HbA1c o7.0 percent also increased by 19 percent in the exposure group. The average HbA1c levels decreased more in the exposure group than in the controls. The effect on LDL was not significant. Conclusions. Generalist care managers using computer-supported diabetes management helped increase adherence to guidelines for testing and control of HbA1c levels, leading to improved health status of patients with diabetes.

Care management has been suggested as a method to improve management of chronic disease, but its success can depend on the involvement of primary care physicians, especially with referral to care management. Our objective was to identify and characterize physicians' perspectives of care management in order to gain insight into the rationale for referral to care management. The study took place in primary care clinics within an integrated delivery system. Nineteen primary care physicians with varying levels of involvement with care management participated in the study. We performed a qualitative and quantitative analysis ofsemistructured interviews. Four referral patterns emerged that were related to physicians' recognition of care managers' abilities and how care managers were connected to their practice. Results from this study can be used to more effectively implement similar models of chronic disease management, where physician participation is a critical component for successful implementation.

Using this framework, we isolate components of a CM intervention directly related to improved process of care or patient outcomes. Current efforts to structure CM to include face-to-face time and multiple diseases are discussed.

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Cet article considère deux communautés du Midwest (Sainte-Geneviève au Missouri et la Prairie-du-Rocher en Illinois) et la façon dont elles maintiennent leur héritage français et leur identité franco-américaine à travers la fête annuelle de la Guiannée le 31 décembre. Cette nuit-là, ces communautés d’origine française, aujourd’hui anglicisées, renouvellent leurs liens sociaux et renouent avec leur identité franco-phone. L’auteur montre comment l’esprit des ancêtres se maintient au fur et à mesure du déroulement de la tradition observée et réussit à renforcer l’identité franco-américaine de ces populations en dépit de la perte de l’usage quotidien de la langue française.

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