Sick To Death > Chapter 3 > The Chronic-Care Model
Wagner and his colleagues have developed a model of optimal chronic care, for use as a universally applicable guide to fundamental reforms that aim to improve outcomes for individuals living with chronic illness (Bodenheimer, Wagner, and Grumbach 2002a; Bodenheimer, Wagner, and Grumbach 2002b; Robert Wood Johnson Foundation 2000). Implementing it requires managing and organizing the care system, most often through a staff-model managed-care plan like Group Health of Puget Sound, where the model originated. Essentially the same model guides revisions at a number of integrated delivery systems that include at least hospital, office practice, and home care.
The model focuses on the collaboration between each knowledgeable and motivated patient and his or her care team in the comprehensive, ongoing management of the patient's chronic illness(es). The care system is responsible for developing registries of patients and using them to ensure timely preventive and maintenance services. Since patients are central to managing their own conditions, the model directs attention to ensuring that patients are capable of self-care (Robert Wood Johnson Foundation 2000; Bodenheimer et al. 2002). In addition, the implementation of the model depends on effective information technology.
The chronic-care model has gathered enough support to spur foundations and clinical sites to become engaged in related implementation and evaluation activities (such as Improving Chronic Illness Care and Partnership for Solutions). At least some applications of this model appear to be effective in improving patient experience and system efficiency (Davis, Wagner, and Groves 2000; Wagner et al. 1999; Coleman et al. 1999). But the model has primarily been applied in managed-care settings that do not have many elderly patients, and younger patients are not often in the advanced stages of illness. Thus, the merits of the model have not been directly addressed with the sickest patients, and the model does not highlight issues of special relevance to people near death, such as advance care planning, mobilizing services to the home, family support, or symptom control. Even so, the Medicare reform legislation in 2003 provided for improved projects around this model and for managed-care plans focused upon special-needs populations (Medicare Prescription Drug, Improvement, and Modernization Act 2003). Additionally, the way in which the chronic-care model directs investments in information systems, registries, and self-management support has been an important force for reform of the usual doctor's office, with its paper records and inability to track preventive services or to provide training for self-care.