The Problem
Although we know the essential elements of good care for people with chronic conditions, there is a gap between what we know and what we do. Providers are doing their best, but too often the systems in which they work make it difficult to provide good care. Providers feel unprepared and too rushed to meet the educational, clinical, and psychological needs of chronically ill patients and their caregivers. Patients experience care that is uncoordinated, impersonal, and unsupportive, which often leaves them feeling incapable of meeting the day-to-day needs of living with a chronic condition. By changing systems, we are closing that gap — and we can prove it. Hundreds of health care provider organizations have already shown impressive improvements in the health of those they serve.
Better Models of Care Exist
To overcome these gaps, Improving Chronic Illness Care, led by Ed Wagner, MD, MPH, has developed a Chronic Care Model to assist organizations in transforming the way that they care for patients with chronic illness.
The Chronic Care Model identifies six essential elements of a system that encourages high-quality chronic disease management:
Focusing on these components should foster productive interactions between patients who take an active part in their care and providers supported by resources and expertise.
The Chronic Care Model can be applied to a variety of chronic illnesses, health care settings, and target populations. The result is healthier patients, more satisfied providers, and cost savings throughout the system.
Improving Chronic Illness Care developed the model using available literature about promising strategies for chronic illness management. The model was further refined during a nine-month planning project supported by The Robert Wood Johnson Foundation, and revised based on input from a large panel of national experts. It was then used to collect data and analyze innovative programs recommended by experts.
Further refinements of the model are anticipated, based on future advances in the care of people with chronic conditions.
CareSouth Carolina, Inc, a community health center located in Hartsville, South Carolina, USA, dramatically improved its recognition rate and clinical outcomes for patients suffering from depression.
Depression Reduction: 40% of patients diagnosed with clinically significant depression will have a 50% reduction in their Patient Health Questionaire (PHQ)
CareSouth Carolina used the Chronic Care Model and evidenced based clinical guidelines to diagnose, treat, and manage the care of patients with depression. For more information on the results achieved by CareSouth Carolina see their improvement story.
Fair Haven Health Center, located in New Haven, Connecticut, USA, has lowered the average hemoglobin A1c (HbA1c) levels for its patients with diabetes.
Average HbA1c Values for Patients with a Diagnosis of Diabetes
An urban health center serving primarily latino and african american populations, Fair Haven Health Center has become a center of excellence in its community. By implementing a patient registry, running individual and group education programs, and partnering with various community organizations, Fair Haven has significanly improved the clinical outcomes for its patients with diabetes. For more information on the results achieved by Fair Haven Health Center see their improvement story.
