Abstract

Patient health management (PHM) was launched as a promising paradigm to close care gaps, the inequities between usual and best care, for whole patient populations. PHM's core premise was that interventions of multidisciplinary, community-oriented partnerships that used repeated measurement and feedback of provider practices, clinical and economic outcomes and general communication of relevant health knowledge to all stakeholders would continuously make things better. This article reviews the evolution of PHM from its genesis in a series of casual hospital-based networks to its maturation in a province-wide, community-focused, clustered-lattice social network that facilitated the improved clinical and cost-efficient care and outcomes of whole patient populations. The factors underlying PHM's clinical and cost efficacy, specifically its patient-centric social networking structures and integral measurement and knowledge translation processes, offer continuing promise to optimally manage the care of our increasingly aged patient populations, with their high burden of chronic diseases and disproportionately large care gaps. In an era when patients are demanding and leading change, and governments are struggling fiscally, PHM's clinical efficacy and cost-efficiency are especially resonant. Things can be better.