Improving Chronic Illness Care

An RWJF National Program

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.

Key Results

  • The program's clinical improvement program engaged dozens of practices and health systems in Breakthrough Series Collaboratives around the country. These collaboratives collectively involved over 1,500 different practice organizations.

    Staff of the program published 99 articles in academic publications and made some 350 presentations to academic and practitioner audiences. The ICIC Web site grew into a vital hub for resources, information and communication for the chronic illness care field.

    A 2009 review, published in Health Affairs, looked at practices’ and systems’ experience in implementing the Chronic Care Model (CCM) and concluded that "… practices redesigned in accord with the CCM generally improve the quality of care and the outcomes for patients with various chronic illnesses. This finding appears to be consistent in both U.S. and international settings."

    The Chronic Care Model has been embedded into a number of national health system reform and improvement efforts.

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