Institute for Healthcare Improvement: Changes

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There are six fundamental areas identified by the Chronic Care Model making up a system that encourages high-quality chronic disease management. Organizations must focus on these six areas, as well as develop productive interactions between patients who take an active part in their care and providers backed up by resources and expertise.

The changes described here can be applied to a variety of chronic illnesses, health care settings, and target populations.

Chronic Care Model

[Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.]

*The Chronic Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and colleagues of the Improving Chronic Illness Care program with support from The Robert Wood Johnson Foundation.

For more information and general tips on selecting changes, see Improvement Methods.

Self-Management
Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health.

Decision Support
Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner.

Delivery System Design
The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.

Clinical Information System
A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care.

Organization of Health Care
Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.

Community
To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs.



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