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Popul Health Manag. 2017 Feb;20(1):23-30. doi: 10.1089/pop.2016.0076. Epub 2016 Aug 26.

An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions.

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1 Jefferson College of Population Health , Philadelphia, Pennsylvania.
2 Evolution Health , Dallas, Texas.


Although the health care reform movement has brought about positive changes, lingering inefficiencies and communication gaps continue to hamper system-wide progress toward achieving the overarching goal-higher quality health care and improved population health outcomes at a lower cost. The multiple interrelated barriers to improvement are most evident in care for the population of patients with multiple chronic conditions. During transitions of care, the lack of integration among various silos and inadequate communication among providers cause delays in delivering appropriate health care services to these vulnerable patients and their caregivers, diminishing positive health outcomes and driving costs ever higher. Long-entrenched acute care-focused treatment and reimbursement paradigms hamper more effective deployment of existing resources to improve the ongoing care of these patients. New models for care coordination during transitions, longitudinal high-risk care management, and unplanned acute episodic care have been conceived and piloted with promising results. Utilizing existing resources, Mobile Integrated Healthcare is an emerging model focused on closing these care gaps by means of a round-the-clock, technologically sophisticated, physician-led interprofessional team to manage care transitions and chronic care services on-site in patients' homes or workplaces.

[Indexed for MEDLINE]
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Conflict of interest statement

Author Disclosure Statement The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article; Ms. Clarke and Dr. Skoufalos are employed by the Jefferson College of Population Health. Drs. Bourn, Beck, and Castillo are employed by Evolution Health, a provider of Mobile Integrated Health services. The authors received the following financial support for this article: The Jefferson College of Population Health received compensation from Evolution Health for manuscript preparation and editorial services.

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