One of the Robert Wood Johnson Foundation's priorities is improving the quality of care delivered to people with chronic illnesses. Improving quality of care was one of the three priorities approved by the board in 1972, shortly after the Foundation became a national philanthropy and it has been a Foundation concern ever since. Among its other efforts, the Foundation has supported quality measurement standards developed by the National Committee for Quality Assurance, commissioned major studies on quality of care by the Institute of Medicine, and funded The Dartmouth Atlas of Health Care, which is the subject of the previous chapter in this Anthology.
In this chapter, freelance journalist Irene Wielawski, a frequent contributor to the Anthology series, explores a Foundation-supported initiative called Improving Chronic Illness Care, a pioneering effort spearheaded by Edward Wagner, M.D., of the Group Health Cooperative in Seattle to provide medical care for chronically ill people, whatever their condition. In tracing the history of the Foundation's efforts to improve quality of care, Wielawski concludes that many of the Foundation's past efforts focused on specific illnesses such as asthma, diabetes, or depression. In contrast, the chronic care model developed by Wagner, around which the Improving Chronic Illness Care Program was built, applies to a broad range of chronic illnesses and serves as a roadmap for physicians to organize their practices to meet the often complex needs of chronically ill people.
In fact, the chronic care model calls for a structural change in the way people with illnesses are cared for, and the participation of nurses, social workers and patients themselves. This chapter highlights how difficult it is to change what goes on in physicians' offices and to modify practices that have been entrenched for many years. The challenge is now one of moving an apparently effective way of improving quality from an experiment carried out primarily in health maintenance organizations to the mainstream of health care practice.