Longitudinal Care Management for Chronic Disease Outcomes

This case study outlines the implementation of a longitudinal care management (LCM) program by Corewell Health aimed at improving chronic disease outcomes, particularly for patients with uncontrolled diabetes. The program was initiated in January 2020 and fully implemented by January 2022, focusing on enhancing patient self-management skills through personalized care interventions. The design team utilized the Scaled Agile Framework for Enterprises (SAFe®) to create cross-functional teams that fostered collaboration and adaptability. The program specifically targeted patients with an A1c of 8 or higher, utilizing risk stratification to identify those at risk for poor health outcomes. The case study documents the challenges faced prior to the redesign, including inconsistent patient engagement and care management practices. It emphasizes the importance of clear communication and structured interventions in achieving better clinical outcomes, such as improved diabetes control and reduced healthcare costs. The findings suggest that effective chronic disease management can lead to significant improvements in patient health and resource utilization.