Improved care for chronic conditions in rural Maine

A grant from The Physician's Foundation for Health Systems Excellence enabled Peninsula Primary Care of Blue Hill, Maine to improve services and outcomes for patients with chronic medical conditions. The project was designed to enhance the use of evidence-based medicine, patient self management and linkages between community resources, patients and providers for patients diagnosed with Diabetes, Hypertension, Hyperlipidemia, Obesity, Heart Failure, COPD and/or Depression. A pre-post evaluation using a quasi-experimental design was implemented. The evaluation measures practice change, patient behavior and outcomes and community-provider linkages.Clinical best practice targets for each condition was achieved and implemented through a consensus building process that involved providers and office staff. The targets covered clinical measurements/treatments, a schedule for their use, and referrals for patient education and support. A Community Health Website was developed to enhance services linkages and information exchange. The website is designed to assist patients in self management, link them to community resources, and educate them on their condition(s). It is also used to educate providers on available resources for patients.The evaluation has two components: a process evaluation to assess project accomplishments and barriers to successful quality improvement in chronic care in a rural community; and an outcomes evaluation to assess project impact on changes in patient health status, use of community resources, practice organization, provider behavior, and patient health outcomes. There have been two rounds of data collection and analysis—results will be reported at this meeting.