How to Make Systems Changes
for Improved Care

Chronic Care Model

This model provides an organizational approach to caring for people with chronic disease in a primary care setting. The system is population-based and creates practical, supportive, evidenced-based interactions between an informed, activated patient and a prepared, proactive practice team. The Chronic Care Model summarizes the basic elements for improving care in health systems at the community, organization, practice and patient levels for chronic illnesses such as diabetes. The model is based on available literature about promising strategies for chronic illness management. The model was refined during a planning project supported by the Robert Wood Johnson Foundation, and revised with input from a large panel of national experts. 4

Permission is granted to reproduce this figure and written material for educational use. Original source is Wagner, EH. Effective Clinical Practice 1998;1:2-4.

A complete description of the components of the model is available at the Improving Chronic Illness Care website (www.improvingchroniccare.org). To achieve improved clinical outcomes it is necessary to develop and utilize:

Clinical Practice Recommendations.
Change concepts are ideas that have been found to be useful in developing specific improvement activities (e.g., all patients with diabetes should have A1C regularly assessed). Clinical practice recommendations summarize change concepts for disease states. Clinical practice recommendations for diabetes care are available from the American Diabetes Association (click here or go to resources) and other professional organizations. However, in order to achieve acceptance and use of the guideline it is often necessary to develop local clinical practice recommendations.5 The process for local development is outlined in the following table. Guidelines require ongoing review and updating. 6

Productive Interactions.
The elements of good chronic illness care require productive clinical interactions between informed activated patients and prepared proactive practice teams. An informed activated patient understands the disease process, and realizes his/her role as the daily self-manager. The proactive team members have the patient information, decision support, people, equipment, and time required to deliver evidence-based clinical management and self-management support at the time of the visit. A thorough assessment is conducted and clinical management is guided by tailoring clinical management protocols to the needs and preferences of the patient. As a result of their interaction a shared care plan is developed including goal setting and problem solving. Active, sustained followed up ensures progress toward meeting the goals and amending management to meet them.

Support from the health system and the community is necessary to facilitate the productive interaction between patients and providers. The key elements required from them include:

• Health Care Organization
  • Goals for chronic illnesses are a measurable part of the organization's annual business plan.
  • Benefits that health plans provide are designed to promote good chronic illness care.
  • Provider incentives are designed to improve chronic illness care.
  • Improvement strategies that are known to be effective are used to achieve comprehensive system change.
  • Senior leaders visibly support improvement in chronic illness care.
    
• Community Resources and Policies
  • Effective programs are identified and patients are encouraged to participate.
  • Partnerships with community organizations are formed to develop evidence-based programs and health policies that support chronic care.
  • Health plans coordinate chronic illness guidelines, measures and care resources throughout the community.

Specific elements within health care organizations for proper chronic illness care include:

• Self-management Support
  • Providers emphasize the patient's active and central role in managing their illness.
  • Standardized patient assessments include self-management knowledge, skills, confidence, supports, and barriers.
  • Effective behavior change interventions and ongoing support with peers or professionals are provided.
  • Collaborative care planning and assistance with problem solving are assured by the care team.
    
• Decision Support
  • Evidence based guidelines are embedded into daily clinical practice.
  • Specialist expertise is integrated into primary care.
  • Provider education modalities proven to change practice behavior are utilized.
  • Patients are informed of guidelines pertinent to their care.
    
• Delivery System Design
  • Team roles are defined and tasks delegated.
  • Planned visits are used to provide care.
  • Continuity is assured by the primary care team.
  • Regular follow-up is ensured.
    
• Clinical Information Systems
  • There is a registry with clinically useful and timely information.
  • Care reminders and feedback for providers and patients are built into the information system.
  • Relevant patient subgroups can be identified for proactive care.
  • Individual patient care planning is facilitated by the information system.
    

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