How Does Chronic Condition Care Work at Partners HealthCare?

Chronic condition care focuses on long-term illness and recovery, and often involves both medical treatment and changes in lifestyle. Diabetes and high blood pressure (hypertension) control are examples of chronic condition care. Care coordination, especially with outpatient specialists, is an important aspect of chronic condition care. That’s why Partners HealthCare, with its extensive network of specialists, can provide effective care for chronic illnesses that require complicated or unusual treatment – often designed specifically to suit your needs.

The Partners System at Work

• At Partners, we use data provided by the Centers for Medicare & Medicaid Services (CMS) and the National Health & Safety Network (NHSN) among others (for inpatient data) and our electronic health record (EHR) derived measures (for ambulatory data) to give us a better understanding of the quality and impact of the chronic condition care our patients receive at our hospitals and outpatient clinics. Since much of chronic condition care happens at the primary care level, we’re increasingly relying on real-time based patient data collected from our medical practices via our EHR – a significant innovation in the industry.
• Measurement is only one step. We strive for excellence in managing our chronic care patients across the system and provide Partners Population Health Care Coordinators to ensure appropriate follow up care interventions are taken.
• Why does that matter? Sharing data and best practices allows uniform delivery of outstanding care everywhere in our system, including at home. We can also target care when and where it’s most needed – to deliver the biggest impact on the quality of life of patients.
• The scale of the Partners system gives patients and providers choices when it comes to where individuals will most benefit from care from inpatient rehabilitation facilities to long-term acute care facilities to ambulatory rehabilitation clinics to home care.
• Through Partners Connected Health, we leverage innovative technology to help patients in their own care and to keep them healthier longer.

Patient Impact 

Featured Measures