Chronic Care Model

The Care Transitions project will be using the Chronic Care Model as a framework or model for health care delivery in the Lower Rio Grande Valley.

The Chronic Care Model maps how health systems can be improved through integrated involvement from patients, caregivers, physicians and other providers. The Model illustrates how integrated strategies of self-management support, delivery system design, decision support and clinical information systems can foster productive interactions and bring about improved outcomes.

The Chronic Care Model promotes effective changes in provider groups to support evidence-based clinical and quality improvement across a wide variety of health care settings. More than 133 million Americans live with a chronic condition,1 and nearly half of those have multiple conditions. This population is expected to increase by more than 1 percent per year, perhaps totaling as many as 171 million people by 2030.

The prevalence of chronic illness in the U.S. health care system has prompted a review of care management systems, shifting the focus to seeking a proactive system of care, one that strives to keep people as healthy as possible.2,3,4

For a detail review of the Chronic Care Model, go to the Improving Chronic Care Illness Website. This site is a clearinghouse of information, tools and other resources that you will find helpful in learning more about this quality improvement initiative.

Sources

1 Partnership for Solutions: Johns Hopkins University, Baltimore, MD for the Robert Wood Johnson Foundation (September 2004 Update). "Chronic Conditions: Making the Case for Ongoing Care"

2 E.H. Wagner, B.T. Austin and M. Von Korff, "Improving outcomes in chronic illness", Managed Care Quarterly 4 (1996): (2) 12-25

3 E.H. Wagner, B.T. Austin and M. Von Korff, "Organizing care for patients with chronic illness", Milbank Quarterly 74 (1996): 511-544

4 E. Calkins, C. Boult, E.H. Wagner and J. Pacala, "New Ways to Care for Older People: Building Systems Based on Evidence", New York: Springer; (1999)