Improving Chronic Illness Care: Translating Evidence Into Action

TLDR

Chronic illness patients face obstacles in care, with systems designed for acute illness failing to meet their needs, while mounting evidence supports effective system changes. The study aims to describe the Chronic Care Model and its application in quality improvement across more than 100 health care organizations. It details how the CCM was implemented in intensive quality improvement activities and the insights gained. The authors summarize evidence in the CCM to guide quality improvement.

Abstract

The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.