# Presentation: 702443

## Chronic Care Model	

- Sandra L. Piñeros, PA-C MPH
- Created by Edward H. Wagner, MD MPH
- Group Health Cooperative
- Puget Sound, WA

## Slide 2

**Notes:**
The intention is for the model to be used as a concrete guide to effective chronic care management and ultimately improving outcomes.  It is a rethinking of primary care practice which focuses on “sick care” as opposed to “wellness care”.

## Overview of the Chronic Care Model

- Six Interdependent Components
- The community
- The health care system
- Self management support
- Delivery system design
- Decision support
- Clinical information systems

**Notes:**
Linkages with community based resources: exercise programs, senior centers, patient education classes, etc.
Health care organizations: foundation upon which the remaining 4 components rest.  An organization’s leaders and goals need to view chronic care management as a priority.  It is difficult to sustain a quality improvement program if purchasers and insurers fail to find this a priority
Self-management support:
Patients as the principal care-givers. Management can be taught  including diet, exercise, self-measurement and medication use/compliance.  The support involves collaboratively helping patients and families acquire skills and confidence to manage their chronic illness providing tools and routinely assessing progress and problems.
Delivery System Design:
The structure of medical practice is altered creating a clear division of labor and separating acute care from planned management of chronic conditions.
Decision Support:
Standards for optimal chronic care in the form of evidence-based clinical practice integrated into daily practice in the form of reminders and physician “champions”.
Clinical Information Systems:
Computerized information as reminder systems, feedback to providers and as registries.  

## Chronic Care Workshop Presenters

- Dr. Rose Mary Pries
- Self-management tools
- Decision Support in the form of physician education
- Dr. Kate Lorig
- Patient self-management and support
- Community resources
- Health care organization

- Dr. Edmund Chaney
- All components of the model
- Dr. Madhu Agrawal and Beth Powell
- Self-management support
- Clinical Information systems
- Dr. Keith Humphreys
- Self-management support
- Community resources

## Results of structured review

- 39 studies reviewed according to the chronic care model components
- No single component of the chronic care model emerged as essential or superfluous for effectiveness
- Supported the conclusion that the chronic care model through multifaceted interventions can improve process and outcome measures for diabetes

**Notes:**
Another result of this review showed that the more components used the more positive and significant were the outcomes (relates to point number 3)

## References

- Bodenheimer T, Wagner EH, Grumbach K.  Improving primary care for patients with chronic illness.  JAMA 2002;288:1775-1779.
- Bodenheimer T, Wagner EH, Grumbach K.  Improving primary care for patients with chronic illness: The Chronic Care Model, Part 2.  JAMA 2002;288:1909-1914.
- http://www.improvingchroniccare.org/change/model/components.html.