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Medicine & Chronic Illness |
Improving Chronic Illness Care: Translating Evidence Into Action
Edward H. Wagner,
Brian T. Austin,
Connie Davis,
Mike Hindmarsh,
Judith Schaefer and
Amy Bonomi
The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.
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H. M. Krumholz, P. M. Currie, B. Riegel, C. O. Phillips, E. D. Peterson, R. Smith, C. W. Yancy, and D. P. Faxon
A Taxonomy for Disease Management: A Scientific Statement From the American Heart Association Disease Management Taxonomy Writing Group
Circulation,
September 26, 2006;
114(13):
1432 - 1445.
[Abstract]
[Full Text]
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W. P. Newton and C. A. DuBard
Shaping the Future of Academic Health Centers: The Potential Contributions of Departments of Family Medicine
Ann. Fam. Med,
September 1, 2006;
4(suppl_1):
S2 - S11.
[Abstract]
[Full Text]
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L. A. Petersen, L. D. Woodard, T. Urech, C. Daw, and S. Sookanan
Does Pay-for-Performance Improve the Quality of Health Care?
Ann Intern Med,
August 15, 2006;
145(4):
265 - 272.
[Abstract]
[Full Text]
[PDF]
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C. L. Roumie, T. A. Elasy, R. Greevy, M. R. Griffin, X. Liu, W. J. Stone, K. A. Wallston, R. S. Dittus, V. Alvarez, J. Cobb, et al.
Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial.
Ann Intern Med,
August 1, 2006;
145(3):
165 - 175.
[Abstract]
[Full Text]
[PDF]
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C. M. Mangione, R. B. Gerzoff, D. F. Williamson, W. N. Steers, E. A. Kerr, A. F. Brown, B. E. Waitzfelder, D. G. Marrero, R. A. Dudley, C. Kim, et al.
The Association between Quality of Care and the Intensity of Diabetes Disease Management Programs
Ann Intern Med,
July 18, 2006;
145(2):
107 - 116.
[Abstract]
[Full Text]
[PDF]
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J. Leeman
Interventions to Improve Diabetes Self-management: Utility and Relevance for Practice.
The Diabetes Educator,
July 1, 2006;
32(4):
571 - 583.
[Abstract]
[Full Text]
[PDF]
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K. C. Stange and R. S. Gotler
In this Issue: Mixed Methods and Diverse Perspectives
Ann. Fam. Med,
July 1, 2006;
4(4):
290 - 291.
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L. I. Solberg, A. L. Crain, J. M. Sperl-Hillen, M. C. Hroscikoski, K. I. Engebretson, and P. J. O'Connor
Care Quality and Implementation of the Chronic Care Model: A Quantitative Study
Ann. Fam. Med,
July 1, 2006;
4(4):
310 - 316.
[Abstract]
[Full Text]
[PDF]
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D. J. Cohen, L. C. Leviton, N. Isaacson, A. F. Tallia, and B. F. Crabtree
Online Diaries for Qualitative Evaluation: Gaining Real-Time Insights
American Journal of Evaluation,
June 1, 2006;
27(2):
163 - 184.
[Abstract]
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P. B. Gold, S. M. Glynn, and K. T. Mueser
Challenges to Implementing and Sustaining Comprehensive Mental Health Service Programs
Eval Health Prof,
June 1, 2006;
29(2):
195 - 218.
[Abstract]
[PDF]
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B. Friedman, H. J. Jiang, A. Elixhauser, and A. Segal
Hospital Inpatient Costs for Adults with Multiple Chronic Conditions
Med Care Res Rev,
June 1, 2006;
63(3):
327 - 346.
[Abstract]
[PDF]
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K. Uhlig, E. M. Balk, J. Lau, and A. S. Levey
Clinical Practice Guidelines in nephrology--for worse or for better
Nephrol. Dial. Transplant.,
May 1, 2006;
21(5):
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G. E. Alkema, J. Y. Reyes, and K. H. Wilber
Characteristics Associated With Home- and Community-Based Service Utilization for Medicare Managed Care Consumers
Gerontologist,
April 1, 2006;
46(2):
173 - 182.
[Abstract]
[Full Text]
[PDF]
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S. D. Yaggy, J. L. Michener, D. Yaggy, M. T. Champagne, M. Silberberg, M. Lyn, F. Johnson, and K. S. H. Yarnall
Just for Us: An Academic Medical Center-Community Partnership to Maintain the Health of a Frail Low-Income Senior Population
Gerontologist,
April 1, 2006;
46(2):
271 - 276.
[Abstract]
[Full Text]
[PDF]
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M. P. Rosenthal, F. D. Butterfoss, L. J. Doctor, L. A. Gilmore, J. W. Krieger, J. R. Meurer, and I. Vega
The Coalition Process at Work: Building Care Coordination Models to Control Chronic Disease
Health Promot Pract,
April 1, 2006;
7(2_suppl):
117S - 126S.
[Abstract]
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R. E. Glasgow, P. A. Nutting, D. J. Toobert, D. K. King, L. A. Strycker, M. Jex, C. O'Neill, H. Whitesides, and J. Merenich
Effects of a brief computer-assisted diabetes self-management intervention on dietary, biological and quality-of-life outcomes
Chronic Illness,
March 1, 2006;
2(1):
27 - 38.
[Abstract]
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J. Nobel
Bridging the knowledge--action gap in diabetes: information technologies, physician incentives and consumer incentives converge
Chronic Illness,
March 1, 2006;
2(1):
59 - 69.
[Abstract]
[PDF]
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J. A. Schmittdiel, S. M. Shortell, T. G. Rundall, T. Bodenheimer, and J. V. Selby
Effect of Primary Health Care Orientation on Chronic Care Management
Ann. Fam. Med,
March 1, 2006;
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[Abstract]
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J. D. Piette and E. A. Kerr
The impact of comorbid chronic conditions on diabetes care.
Diabetes Care,
March 1, 2006;
29(3):
725 - 731.
[Full Text]
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J. J. Davis and W. C. Bailey
Teach a man to fish and you have fed him for a lifetime.
Chest,
February 1, 2006;
129(2):
220 - 221.
[Full Text]
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P. G. Szilagyi, A. W. Dick, J. D. Klein, L. P. Shone, J. Zwanziger, A. Bajorska, and H. L. Yoos
Improved Asthma Care After Enrollment in the State Children's Health Insurance Program in New York
Pediatrics,
February 1, 2006;
117(2):
486 - 496.
[Abstract]
[Full Text]
[PDF]
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J. Beich, D. P. Scanlon, J. Ulbrecht, E. W. Ford, and I. A. Ibrahim
The Role of Disease Management in Pay-for-Performance Programs for Improving the Care of Chronically Ill Patients
Med Care Res Rev,
February 1, 2006;
63(1_suppl):
96S - 116S.
[Abstract]
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S. J. Spann, P. A. Nutting, J. M. Galliher, K. A. Peterson, V. N. Pavlik, L. M. Dickinson, and R. J. Volk
Management of Type 2 Diabetes in the Primary Care Setting: A Practice-Based Research Network Study
Ann. Fam. Med,
January 1, 2006;
4(1):
23 - 31.
[Abstract]
[Full Text]
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