The Issue

Primary care practices often do well managing their patients with chronic conditions who keep in regular contact with the practice, but have less success finding and helping patients who don't make appointments or follow recommended treatment plans.

The Innovation

Martin's Point Health Care, a Maine-based nonprofit primary care health system, improved care for patients with chronic disease by reorganizing practices around care teams that include a physician, a nurse, a medical assistant, and a patient-service representative. The teams have identified patients whose chronic conditions are uncontrolled and devised methods of meeting their needs, such as supplying loaner blood pressure cuffs to patients with uncontrolled hypertension. Population health tools including registries have helped providers proactively manage care.


In pilot practices, the percentage of patients with controlled hypertension increased to 82 percent in July 2010 from 55 percent in July 2007. The practices are now targeting patients with uncontrolled lipidemia.