Caring for chronic diseases in a “fragmented” health care system

Ed Wagner, MD, MPH set out 15 years ago to explore how best to engage patients with chronic diseases in effective care. With Robert Wood Johnson Foundation support, he and his colleagues developed the Chronic Care Model.

More than 1,500 US and international medical practices have adopted the model. Now the largest roundup of evidence on how the model performs in practice confirms that it works. This review is in the January/February 2009 issue of Health Affairs, focused on a key part of reforming health care: caring for chronic diseases in a “fragmented” health care system.
 
The Chronic Care Model is a framework to redesign daily medical practice. It aims to transform the health care system from acute and reactive to proactive and planned, and based more on evidence about populations, less on habit.

Chronic diseases include diabetes, depression, and asthma. The world’s main cause of death and disability, they are becoming more common as populations age.

“Redesigning medical practices according to the model generally improved health care and helped patients control a broad range of chronic diseases,” a review co-author said. Reviewing 82 studies published since 2000, it was found the model helped people stay healthier and get better care.
 
The Chronic Care Model comprises six interrelated system changes: effective team care; planned interactions; self-management support; community resources; integrated decision support; and patient registries and other supportive information technology (IT).

Registries track patients with specific chronic diseases, helping medical teams to make the most of each office visit and follow evidence-based care guidelines. Electronic medical records, while useful, are not required. “There’s no magic bullet, including IT,” said Brian Austin, another review co-author, who is the associate director of Group Health’s MacColl Institute. “No single element suffices alone.”
 
Controlling chronic diseases better should save money. But the review concluded that realising these savings may take longer than the studies, most of which ended within a year. And insurers, not healthcare providers, may get the savings. That is because most healthcare is reimbursed as fees for services – tests and treatments – not for patient support or disease control or prevention.