The United States leads the world in health care costs but ranks far below many developed countries in health outcomes. Finding ways to narrow this gap remains elusive. This article describes the response of one state to establish community health networks to achieve quality, utilization, and cost objectives for the care of its Medicaid recipients. The program, known as Community Care of North Carolina, is an innovative effort organized and operated by practicing community physicians. In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost since their inception a decade ago. The program is now saving the State of North Carolina at least $160 million annually. A description of this experience and the lessons learned from it can inform others seeking to implement effective systems of care for patients with chronic illness. 1 Despite these high expenditures, the quality of care remains unsatisfactory. For example, only 27% of patients with hypertension have adequate blood pressure control, and only 17% of patients with coronary artery disease have cholesterol at levels suggested by national guidelines. 2 The United States ranks last in preventable deaths among 19 Organization for Economic Cooperation and Development (OECD) countries. 3 One reason for this quality gap is that, although the prevalence of chronic disease is increasing, our health care delivery system is based on a model that is best suited to episodic care for acute illnesses. Optimal delivery of chronic care and preventive services requires restructuring our health care system. In recent years, much research and discussion have focused on how best to adapt our system to chronic care and prevention. For example, the Chronic Care Model lays out several key elements of high-quality care for chronic diseases, including community resources, health care organization, self-management support, delivery system design, decision support, and clinical information systems. 4 More recently the concept of the patient-centered medical home has received widespread attention as a model to improve care. 5 Seven key principles outline the characteristics of the patient-centered medical home: a personal physician, physician-directed medical practice, a whole-person orientation, coordinated care, quality and safety, enhanced access, and a system of payment that refl ects the added value of a patient-centered medical home.Although these models have shown promise in controlled research settings and small demonstration projects, they have been diffi cult to disseminate widely. 6 One problem with implementation of models in indi-
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CO M MUNI T Y C A R E O F NOR T H C A ROL INAvidual practices is that the current funding structure of health care is based on acute care. When practices are reimbursed on a fee-for-service basis for episodic care, fi nding the resources to redesign a practice, develop systems of care, and implement the elements of these new models of care can ...
