Making Health Systems Work for People With Chronic Conditions

One approach to a more proactive health care system is the Chronic Care Model developed by Edward H. Wagner, MD, MPH

    • April 1, 2010

The Issue: Some 133 million people—almost half of all Americans—live with a chronic condition such as diabetes, heart disease, depression or asthma. That number is expected to swell to 171 million by 2030 as the population ages.

Chronic conditions require ongoing management over years or decades, but most health care systems are not set up to provide this kind of care. Rushed practitioners often fail to follow well-tested practice guidelines and coordinate their care with other providers. Patients do not get the training they need to take more responsibility for their own health. And too often, there is no active follow-up to make sure patients are following treatment plans.

Overcoming these deficiencies will require a transformation of health care from a system that is essentially reactive—focused on treating acute illnesses—to one that is proactive and focused on keeping a person as healthy as possible.

Grantee Background: One approach to a more proactive health care system is the Chronic Care Model developed by Edward H. Wagner, MD, MPH, senior investigator and director of the MacColl Institute for Healthcare Innovation at the Group Health Research Institute in Seattle.

The Chronic Care Model provides a roadmap for improving care in health systems at the organization, practice and patient levels. The model forms the conceptual core of RWJF's Improving Chronic Illness Care national program.

The seeds of the model can be found in several key experiences Wagner had over his career, beginning with his service as a battalion surgeon during the Vietnam War.

There, Wagner developed a system, described in his first published paper in 1967, that allowed surgeons to travel by helicopter to make sick calls to troops in the field. It was, in retrospect, his first attempt to make room for the care of chronic health problems in a system geared primarily toward acute treatment.

Wagner says he learned a second lesson while working at a rural health care center in North Carolina during the 1970s. He and his colleagues found that making even small changes to standard care—such as keeping better records and making certain that patients took their medicine and came to appointments—resulted in big changes in the health of people with chronic high blood pressure, which was a huge problem among African Americans in that region.

Yet, making changes was difficult and often stalled in practice settings. "It wasn't that they [the practitioners] weren't well meaning or well educated. It had nothing to do with the characteristics of the individual physicians or their motivation. The design of their practice just made it difficult, if not impossible."

Grantee Approach: In the 1990s, Wagner worked with a quality improvement committee charged with improving diabetes care at the Seattle-based Group Health. After trying out a number of ideas over the course of a year, the committee rebelled. "They said, 'It's one idea after the other,'" Wagner recalls. "'What's the connection? Let's see the whole of what we're doing.'"

Someone got up and started drawing squares and circles on the board representing the elements needed for high-quality chronic illness care. Those jotted notes became the basis for the Chronic Care Model, a graphic that shows how the various pieces of chronic illness management relate to and depend on one another.

The model calls for replacing the traditional physician-centric office structure with one that supports clinical teamwork in collaboration with the patient:

  • Clinicians encourage patients with chronic illness to participate in setting goals and fine-tuning treatment.
  • Clinical staff members have defined roles and tasks and follow up with patients regularly to support them in managing their own diseases.
  • Doctor's offices and clinics know about existing community resources that can help their patients and they encourage patients to participate.
  • Clinicians use explicit guidelines, whether the issue is scientific (drug doses) or psychological (how best to motivate overweight diabetics to diet).
  • The office uses computers efficiently to deliver disease management information, including care guidelines, test results and even pop-up reminders about individual patients.
  • The health system, as a whole, pursues excellence visibly—creating strategies for improvement as well as encouraging open communication about errors and failings.

"[The model] puts the patient's role right in the middle of quality improvement," Wagner says. "It is important to work on improving the care system...but if the patient isn't actively participating in managing their illness, then we are not doing well."

RWJF funded a rigorous review of the model. In 1998, RWJF launched its Improving Chronic Illness Care national program, using the model as its conceptual core.

Under Wagner's leadership, the program has supported broad dissemination and testing of the model—in private practices, large health care systems, and among safety-net organizations, such as community health centers, public hospitals and the Indian Health Service.

In the 2000s, growing numbers of initiatives across the country adopted the Chronic Care Model, including efforts in Indiana, North Carolina, California, Vermont, Pennsylvania and New York. The model has influenced the redesign of care delivery in the United Kingdom, Australia, Denmark and other countries as well as several Canadian provinces.

For his work, Wagner has received recognition from several organizations in the field, including a 2007 Health Quality Award from the National Committee for Quality Assurance and the 2007 Award for Excellence in the Advancement of Patient-Centered Care from the Picker Institute. He also received the 2010 Founder's Award of the American College of Medical Quality.

Wagner is quick to acknowledge the contributions of the many colleagues he has worked with in the development and dissemination of the Chronic Care Model.

"What bothers me about all of this is that it is all in my name," Wagner says. "I know [awards] work this way, but this has been a collaborative effort from the beginning."

RWJF Perspective: Since its creation as a national philanthropy in 1972, RWJF has pursued the goal of improving the quality of health care. Many of the RWJF's previous efforts focused on specific illnesses, such as asthma, diabetes or depression; or specific populations, such as minorities or the underserved. But with the burden of chronic illness growing, by the 1990s, the Foundation was looking for a more promising strategy for improving care.

RWJF created the Improving Chronic Illness Care program in 1998 to help provide leadership for structural changes in the way chronically ill patients are cared for.

"The Chronic Care Model helped RWJF move away from fragmented grantmaking, to recognizing that we could do far more than we were doing," says C. Tracy Orleans, PhD, RWJF distinguished fellow and senior scientist.

"Our basic approach had been to educate physicians about evidence-based care and patients about their health care risks, with the goal of changing the behaviors that got in the way of quality care," Orleans says. "What we found was that trying harder won't work. We came to see that what determines behavior is the environment in which you work, and the broader social environment.

"Wagner's thinking and vision, as seen in the Chronic Care Model, have now become part of the DNA of how we think about chronic illness care at RWJF and the way we approach health care improvement."

Seeing the model implemented in various health care settings has helped to ignite a regional strategy for quality improvement that holds great promise, Orleans says. That regional strategy is embedded in Aligning Forces for Quality, RWJF's $300 million commitment to improve health care in 15 communities that together cover 11 percent of the U.S. population.