Key Recommendations: The project recommended that existing or evolving programs of care coordination in Kaiser focus on:
- Improving surveillance of patients with multiple chronic and medical conditions.
- Detecting patterns where poor patient outcome is associated with management by more than one physician, e.g., allowing those patients to be seen by only one physician.
- Improving medication management.
- Improving pain management.
- Reducing the incidence of risky behaviors, particularly smoking and overweight, which affect long-term management of chronic illnesses such as diabetes, circulatory disorders and/or obstructive pulmonary disorders.