Chronic Disease

The chronic care model improves care delivery and patient outcomes, but practices need better tools to implement it

The goal of the chronic care model (CCM) is to transform the daily care of patients with chronic illnesses from acute and reactive to proactive and planned. Practices redesigned in accord with the CCM generally improve care delivery and the outcomes of patients with various chronic illnesses, concludes a review of the literature. However, practices need better tools to implement the model. Katie Coleman, M.S.P.H., along with colleagues that include Cindy Brach, M.P.P., of the Agency for Healthcare Research and Quality, examined the CCM's effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference.

The evidence suggests that the CCM works as an integrated framework to guide practice redesign. The CCM was designed to build on the interrelationships between six evidence-based elements that lead to improved clinical quality. For example, for patients to engage in proactive care (delivery system redesign), practices need to be able to view all of the patients in their panels (clinical information systems) who need certain guideline-based treatments (decision support), and patients must agree to any changes in their care and integrate them into their lives (self-management support).

Practices seem to give the most attention to information systems and the least attention to community linkages. Early collaborative projects demonstrated that implementing the CCM costs practices money in the short term, but doing so improves health outcomes and may save money in the long run. Evidence on the cost-effectiveness of the CCM is just beginning to emerge. External financial incentives and quality improvement support may be needed for widespread practice change, especially for small practices.

See "Evidence on the chronic care model in the new millennium," by Katie Coleman, M.S.P.H., Brian T. Austin, B.A., Ms. Brach, and Edward H. Wagner, M.D., M.P.H., in the January/February 2009 Health Affairs 28(1), pp. 75-85. Reprints (AHRQ Publication No. 09-R016) are available from the AHRQ Publications Clearinghouse.

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