1. The Chronic Care Model

2. Developed by Ed Wagner, MD, MPH and colleagues
MacColl Institute for Healthcare Innovation
Group Health Cooperative of Puget Sound
home of the
Robert Wood Johnson Foundation National Program,
Improving Chronic Illness Care
Module 3- Intro to ICIC Model

3. The IOM Quality report: A New Health system for the 21st Century

4. The IOM Quality report: A New Health system for the 21st Century
“The current care systems cannot do the job.”
“Trying harder will not work.”
“Changing care systems will.”

5. Usual Chronic Illness Care
15 minute visit, poorly organized
Symptoms and lab results focus of discussion and exam, not preventive assessment
Patient’s attempts to discuss difficulties in living with the condition are discouraged
Focus is on physician’s treatment, not patient’s role in management.
Treatment plan is limited to prescription refill and encouragement to make appointment if not feeling well
Visit ends with physician rifling through drawers looking for a pamphlet
improving chronic illness care
Module 3- Intro to ICIC Model

6. Functional and Clinical Outcomes
Usual Care Model
Health System
Health Care Organization
Leadership concerned about the bottom line
Incentives favor more frequent, shorter visits
No organized QI
Community
Resources and Policies
No links with community agencies or resources
Clinical
Information Systems
Don’t know pts or what they need
Self-Management
Support
No systematic approach; didactic in orientation
Decision Support
No agreement on good care; traditional referrals
Delivery
System Design
Reliance on short, unplanned visits
Frustrating
Problem-Centered
Interactions
Uninformed,
Passive
Patient
Unprepared
Practice Team
Sub-optimal
Functional and Clinical Outcomes
improving chronic illness care
Module 3- Intro to ICIC Model

7. Usual Care Model Frustrating Problem-Centered Interactions
Unprepared
Practice
Team
Uninformed,
Passive
Patient
Sub Optimal Functional and Clinical Outcomes
improving chronic illness care
Module 3- Intro to ICIC Model

8. Chronic Care Model Productive Interactions
Informed, Activated
Patient
Supportive,
Integrated
Community
Prepared,
Proactive
Practice Team
Productive Interactions
Functional and Clinical Outcomes
Satisfaction  Clinical Measures  Cost  External Review Measures
Module 3- Intro to ICIC Model

9. Chronic Care Model Development 1993 --
Initial experience at GHC
Literature review
RWJF Chronic Illness Meeting -- Seattle
Review and revision by advisory committee (40 members (32 active participants)
Interviews and site visits with 72 nominated “best practices”
Model applied with diabetes, geriatrics, asthma, CHF, and depression with over 200 health care organizations
Module 3- Intro to ICIC Model

10. Themes in the Chronic Care Model
Evidence-based
Valuing excellence (and evidence) over autonomy
Patient-centered
Each patient is the only patient
Population-based
Module 3- Intro to ICIC Model

11. The Chronic Care Model Community Health System Resources and Policies
Health Care Organization
Family Education & Self- Management Support
Delivery System
Design
Decision
Support
Clinical Information Systems
Informed,
Activated Patient
I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective.
As you can see, there are a number of elements:
At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system.
Let me give you some specific examples of each element of the model.
Supportive,
Integrated
Community
Prepared,
Proactive
Practice Team
Productive Interactions
Functional and Clinical Outcomes
Module 3- Intro to ICIC Model

12. Chronic Care Model Community Health System Health System
Resources and Policies
Health System
Health Care Organization
Health System
Clinical Information Systems
Family Education & Self-Management Support
Delivery System
Design
Decision
Support
Specific goals in organizations strategic/business plan
Senior leader support
Organization adopts performance improvement model
Provider incentives support organizational goals
I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective.
As you can see, there are a number of elements:
At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system.
Let me give you some specific examples of each element of the model.
Module 3- Intro to ICIC Model

13. Clinical Information Systems
Chronic Care Model
Community
Health System
Resources and Policies
Health Care Organization
Delivery System
Design
Clinical Information Systems
Decision
Support
Family Education & Self- Management Support
Evidence-based guidelines
Provider education
Referrals and specialist expertise
Guidelines for patients
I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective.
As you can see, there are a number of elements:
At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system.
Let me give you some specific examples of each element of the model.
Module 3- Intro to ICIC Model

14. Clinical Information Systems
Chronic Care Model
Community
Resources and Policies
Health System
Health Care Organization
Family Education & Self-Management Support
Delivery System
Design
Decision
Support
Clinical Information Systems
Emphasize patient/parent active role
Collaborative care planning/problem solving
Ongoing educational process
Connections between family/patient and social support
Standardized assessments of self-management
Written management plan with goal setting
I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective.
As you can see, there are a number of elements:
At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system.
Let me give you some specific examples of each element of the model.
Module 3- Intro to ICIC Model

15. Chronic Care Model Community Resources and Policies Health System
Health Care Organization
Family Education & Self-Management Support
Delivery System
Design
Decision
Support
Clinical Information Systems
Team roles and tasks (practice team, school, parents)
Care based on accepted guidelines
Primary care team assures continuity
Regular follow-up care
I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective.
As you can see, there are a number of elements:
At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system.
Let me give you some specific examples of each element of the model.
Module 3- Intro to ICIC Model

16. Chronic Care Model Community Health System Resources and Policies
Health Care Organization
Clinical Information Systems
Family Education & Self-Management Support
Delivery System
Design
Decision
Support
Registry to track clinically useful and timely information
Registry reports/data for feedback
Care reminders
Assure timely planned follow-up
Identification/proactive care of relevant patient subgroups
Individual patient care planning
I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective.
As you can see, there are a number of elements:
At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system.
Let me give you some specific examples of each element of the model.
Module 3- Intro to ICIC Model

17. Chronic Care Model Community Health System Resources and Policies
Health Care Organization
Clinical Information Systems
Family Education & Self-Management Support
Delivery System
Design
Decision
Support
Partnerships
Key school contact identified
Input
Educational services available
I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective.
As you can see, there are a number of elements:
At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system.
Let me give you some specific examples of each element of the model.
Module 3- Intro to ICIC Model

18. How Would I Recognize Good Care for People with Chronic Illness?
Informed,
Activated Patient
Supportive,
Integrated
Community
Prepared, Proactive
Practice Team
Productive Interactions
Functional and Clinical Outcomes
Assessment and tailoring
Collaborative problem definition
Evidence-based clinical management
Goal-setting and problem-solving
Shared care plan
Active, sustained follow-up
Community integration and support
Module 3- Intro to ICIC Model