of its impact also informs the continued development of best practice. The process used by the VHA also emphasizes the broad dissemination of information about best practice throughout their system, from large academic centers to smaller, community-based centers.

The VHA’s approach is consistent with the concept of focusing on priority conditions in that it provides a framework for organizing and continually updating the evidence base, bringing it to the direct delivery of care, and evaluating its effect on improving care for patients. Synthesis and application of the evidence base, therefore, forces the reexamination of how care is organized to affect quality. By examining where current practice departs from the evidence base and best practice, suggestions for improving care may emerge that can direct changes in provider actions, patient responsibilities, or organizational approaches. It would be difficult to use this multifaceted, comprehensive care approach except at the level of a specific condition.

Organize and Coordinate Care Around Patient Needs

The primary purpose of identifying priority conditions is to facilitate the organization of care around the patient’s perspective and needs rather than, as in the current system, around types of professionals and organizations. For example, the current system may require patients to travel to multiple locations to receive care (usually Monday through Friday, between 8:00 a.m. and 5:00 p.m.) instead of using modern technologies to facilitate access even for patients with mobility problems or those living in rural areas. Most hospitals are organized around physician specialties (such as thoracic surgery or internal medicine), not around common clinical needs of patients, which may cross departmental boundaries. (An example is diabetes care, which may require general medicine, endocrinology, ophthalmology, and vascular services.) Organizing care around priority conditions emphasizes meeting the needs of patients with those conditions, regardless of who provides their care or where. Attention must be paid to how care is coordinated across settings and provider types. A surgical procedure may be performed perfectly, but if there is inadequate postoperative care, follow-up care, home care, or other supports, the patient may encounter complications that compromise the quality of the episode of care. It is also important to recognize that patients may have to manage multiple conditions simultaneously, because they either have more than one chronic condition or have one chronic condition and an unrelated acute event. Indeed, there is evidence that patients actively receiving care for one chronic condition may not receive treatment for other, unrelated conditions (Redelmeier et al., 1998). Thus, one of the challenges of designing care around specific conditions is to avoid defining patients solely by their disease or condition.

There are several mechanisms for coordinating care across priority conditions. First, coordination could be performed by a health professional acting as a



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