Field of Work: Improving the care of patients with chronic illness
Problem Synopsis: 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, 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.
Synopsis of the Work: Improving Chronic Illness Care aimed to improve the health of chronically ill patients by helping large numbers of organized health systems redesign how they deliver care. At the heart of the program is the Chronic Care Model (CCM) —an approach that replaces the traditional physician/office-based structure with one that encourages collaboration among patients, physicians, nurses, case managers, dieticians, patient educators, families and friends.
The program supported a clinical improvement program and its evaluation, targeted research projects and an intensive dissemination effort—together aimed at improving the way in which care for chronically ill people is delivered.