Chronic Illness Care
If you are searching for ideas on how to improve chronic illness care in your community, you might consider the Chronic Care Model as an approach.
Background
There are over 99 million Americans who live with chronic health conditions, such as asthma, depression, diabetes, heart disease, and hypertension. Chronic illness is a major driver of rising health expenditures, lost productivity due to illness, and decline in quality of life. People with chronic illness may utilize primary care, specialty care, pharmaceutical care, and other services to control the impact of disease. Local safety net patients -- those who are uninsured or underinsured -- are especially vulnerable because they may lack access to the multi-faceted care they need.
What is the Chronic Care Model?
Improving Chronic Illness Care (ICIC) is a national program of The Robert Wood Johnson Foundation, based at the MacColl Institute for Healthcare Innovation, within the Group Health Cooperative of Seattle.
The program, now in its fifth year, seeks to improve the care of the chronically ill through three main program components:
- Improvement Collaboratives: programs that bring together dozens of health care organizations to improve care for a certain chronic condition. Programs include the Breakthrough Series, operated collaboratively with the Institute for Healthcare Improvement (IHI), as well as regional collaboratives;
- The Targeted Research Grants Program: helps fund peer-reviewed, applied research addressing specific, field-relevant questions in chronic illness management;
- A Dissemination Program: provides technical assistance and support to organizations interested in improving chronic illness care.
These three program components are guided by a team of staff, advisors and consultants working to promote the Chronic Care Model, the practical model at the heart of the Improving Chronic Illness Care (ICIC) program.
The Chronic Care Model emphasizes health system leadership; regular planned patients visits; instant access by clinicians to the latest evidence-based guidelines for care; use of information technology that tracks patients’ health status; goal setting and self-management by patients; and involvement of community resources to keep patients well, involved and active.
The Breakthrough Series methodology brings groups of health care organizations together in team efforts called collaboratives to work with faculty in tandem for a year to improve all aspects of care surrounding a single condition.
To date nearly 800 health care teams, representing hospitals, HMO’s, medical practices and clinics have participated in national and regional collaboratives for asthma, depression, diabetes, hypertension, rheumatoid arthritis and other conditions. Included in among the 800 teams are some 500 of the Health Resources and Services Administration’s Bureau of Primary Health Care (BPHC) federally funded health centers that have completed or are engaged in collaboratives, which it conducts independently, using the Chronic Care Model.
Quality improvement data suggest that the result of the year-long collaboratives are impressive: improvements in glycemic control for patients with diabetes; dramatic increases in follow-up for patients with depression; decreases in blood pressure rates among patients with cardiovascular disease; overwhelming success in providing asthmatic patients with daily preventative medicines; and decreases in health care costs, even with increased patient visits.
ICIC’s Library of Collaborboative Training and Tools includes an Assessment of Chronic Illness Care Survey (ACIC) that can help any organization pinpoint areas of strength and weakness in a system’s chronic illness care.
Organizations can choose how they implement the Chronic Care Model. Implementation can be as basic as downloading a presentation from the ICIC Library of Collaborboative Training and Tools or as intensive as one of ICIC’s year-long improvement collaboratives.
Improving Chronic Illness Care (ICIC) appears committed to disseminating the best in improvement resources to chronic care innovators, providers and researchers. The Chronic Care Model draws on the current research and practice, and provides a foundation for collaborative programs, the tools to implement change and research aimed at improving care for the chronically ill. Bibliographies and model/sample programs are available for a wide range of chronic illnesses.
How can we get started?
Details about the ICIC Chronic Care Model, assessment tools, a bibliography, a video and more information can be found on the Improving Chronic Illness Care (ICIC) website http://www.improvingchroniccare.org Or, contact CHRC for additional technical assistance. interested in improving chronic illness care.
