Health care disparities in minority populations can be attributed to a number of factors, including lack of access to coordinated primary care and chronic disease management programming. Interventions using a data-centric, coordinated, multidisciplinary, team-based approach to address patients with complex chronic comorbidities have demonstrated improvements in patient outcomes. The use of hospital admission and billing data coupled with care management teams to care for high-risk patients with chronic conditions may be an effective model for improving quality of care while reducing health care costs.
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