How physicians can provide better care for patients with chronic conditions

It's well documented that the bulk of patient health outcomes are impacted by factors outside of clinical care, ranging from diet to education to housing. It would seem obvious, then, that quality care between doctor visits is vital for achieving better health outcomes, particularly when it comes to chronically ill patients and those in underserved communities. Yet providers typically don't have the infrastructure necessary to maintain consistent insight into the patient's life and health outside of clinical interactions. And even though most doctors only see patients during brief clinical checkups, they own 100% of the responsibility for the outcomes. Further, there is a gaping hole in the industry's care delivery model, leaving both patients and physicians at a loss. Two huge challenges exist: one related to patients, the other related to providers.