Chronic Care: Wagner's Chronic Care Model

Over 100 million people in the US are suffering from at least one chronic illness. "Three-quarters of the $2 trillion-plus that we spend on U.S. health care each year goes to paying the bills for chronic illness: cardiovascular and pulmonary disease, cancers, diabetes, arthritis, high blood pressure, depression."

The Chronic Care Model focuses on practice improvement for patient-centered evidence-based proactive care of chronically ill populations.

Science and Society's February 2009 edition features an audio interview with Ed Wagner, the father of the Chronic Care Model. The interview reviews the implications of the chronic care model for "redesigning the health care delivery system, creating a better-prepared practice team, and developing methods for increasing patients’ knowledge, skills, and confidence." Improving Chronic Illness Care provides a video overview of the Chronic Care Model by Dr. Wagner.

1500 medical practices are using the Chronic Care Model. The Chronic Care Model "comprises six interrelated system changes: effective team care; planned interactions; self-management support; community resources; integrated decision support; and patient registries and other supportive information technology (IT)."

From a technology perspective, registries, decision support, patient/provider communication, patient education and information exchange for care coordination are all important enablers. "Registries track patients with specific chronic diseases, helping medical teams to make the most of each office visit and follow evidence-based care guidelines."

The chronic care model is designed to address the deficiencies in current practice of chronic care including:

• "Rushed practitioners not following established practice guidelines
• Lack of care coordination
• Lack of active follow-up to ensure the best outcomes
• Patients inadequately trained to manage their illness"

Health Affairs January/February edition was dedicated to The Crisis in Chronic Disease. Susan Dentzer finds that "the evidence continues to pile up that the famed Chronic CareModel developed by Ed Wagner and colleagues at Group Health Puget Sound delivers superior patient care and health outcomes. (The evidence is starting to trickle in about the model’s overall cost-effectiveness.)"

In a recent interview, Dr. Ben Littenberg summarized that "the Chronic Care Model is a very influential idea about how to do a good job in taking care of people with ongoing medical problems like high blood pressure, arthritis, and in our case, diabetes. It tells what resources the health care system must have to get the most out of the interaction between the doctor and the patient. These include systems to support clinical decision making, up-to-date and easy-to-use clinical information, reminders, support for patient self-management, and so on. Turning a typical primary care medical office into a fully-functional chronic care model practice is a good thing, but it is complex, expensive and time-consuming. It requires extensive retraining of the physicians, nurses and other staff, installation of comprehensive electronic medical records systems, changes in the way patients and staff interact, and even an overhaul of the way care is paid for. So, very few practices have successfully transformed themselves."

Roberts Wood Johnson had contracted with Rand to evaluate the impact of the Chronic Care model. "Highlights of the findings include:

• Organizations were able to improve, making an average of 48 changes in 5.8 out of the 6 CCM areas;
• Patients with diabetes had significant decreases to their risk of cardiovascular disease;
• CHF pilot patients more knowledgeable and more often on recommended therapy, had 35% fewer hospital days;
• Asthma and diabetes pilot patients were more likely to receive appropriate therapy.

When contacted a year later, the care teams reported that involvement in the collaboratives was rewarding. Over that year, 82% of sites had sustained the changes and 79% of sites had spread change to other places or diseases."

Dr. Wagner is focusing his current efforts on regional models for chronic care.


The Chronic Care Model was developed in part with support from Robert Woods Johnson grant by Improving Chronic Illness Care with direction and technical assistance from the The MacColl Institute for Healthcare Innovation at the Group Health Center for Health Studies.