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Medicine & Chronic Illness

Improving Chronic Illness Care: Translating Evidence Into Action

Edward H. Wagner, Brian T. Austin, Connie Davis, Mike Hindmarsh, Judith Schaefer and Amy Bonomi

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.


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Eval Health ProfHome page
P. B. Gold, S. M. Glynn, and K. T. Mueser
Challenges to Implementing and Sustaining Comprehensive Mental Health Service Programs
Eval Health Prof, June 1, 2006; 29(2): 195 - 218.
[Abstract] [PDF]


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Med Care Res RevHome page
B. Friedman, H. J. Jiang, A. Elixhauser, and A. Segal
Hospital Inpatient Costs for Adults with Multiple Chronic Conditions
Med Care Res Rev, June 1, 2006; 63(3): 327 - 346.
[Abstract] [PDF]


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Nephrol Dial TransplantHome page
K. Uhlig, E. M. Balk, J. Lau, and A. S. Levey
Clinical Practice Guidelines in nephrology--for worse or for better
Nephrol. Dial. Transplant., May 1, 2006; 21(5): 1145 - 1153.
[Full Text] [PDF]


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The GerontologistHome page
G. E. Alkema, J. Y. Reyes, and K. H. Wilber
Characteristics Associated With Home- and Community-Based Service Utilization for Medicare Managed Care Consumers
Gerontologist, April 1, 2006; 46(2): 173 - 182.
[Abstract] [Full Text] [PDF]


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The GerontologistHome page
S. D. Yaggy, J. L. Michener, D. Yaggy, M. T. Champagne, M. Silberberg, M. Lyn, F. Johnson, and K. S. H. Yarnall
Just for Us: An Academic Medical Center-Community Partnership to Maintain the Health of a Frail Low-Income Senior Population
Gerontologist, April 1, 2006; 46(2): 271 - 276.
[Abstract] [Full Text] [PDF]


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Health Promot PractHome page
M. P. Rosenthal, F. D. Butterfoss, L. J. Doctor, L. A. Gilmore, J. W. Krieger, J. R. Meurer, and I. Vega
The Coalition Process at Work: Building Care Coordination Models to Control Chronic Disease
Health Promot Pract, April 1, 2006; 7(2_suppl): 117S - 126S.
[Abstract] [PDF]


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Chronic IllnessHome page
R. E. Glasgow, P. A. Nutting, D. J. Toobert, D. K. King, L. A. Strycker, M. Jex, C. O'Neill, H. Whitesides, and J. Merenich
Effects of a brief computer-assisted diabetes self-management intervention on dietary, biological and quality-of-life outcomes
Chronic Illness, March 1, 2006; 2(1): 27 - 38.
[Abstract] [PDF]


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Chronic IllnessHome page
J. Nobel
Bridging the knowledge--action gap in diabetes: information technologies, physician incentives and consumer incentives converge
Chronic Illness, March 1, 2006; 2(1): 59 - 69.
[Abstract] [PDF]


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Ann Fam MedHome page
J. A. Schmittdiel, S. M. Shortell, T. G. Rundall, T. Bodenheimer, and J. V. Selby
Effect of Primary Health Care Orientation on Chronic Care Management
Ann. Fam. Med, March 1, 2006; 4(2): 117 - 123.
[Abstract] [Full Text] [PDF]


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Diabetes CareHome page
J. D. Piette and E. A. Kerr
The impact of comorbid chronic conditions on diabetes care.
Diabetes Care, March 1, 2006; 29(3): 725 - 731.
[Full Text] [PDF]


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ChestHome page
J. J. Davis and W. C. Bailey
Teach a man to fish and you have fed him for a lifetime.
Chest, February 1, 2006; 129(2): 220 - 221.
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PediatricsHome page
P. G. Szilagyi, A. W. Dick, J. D. Klein, L. P. Shone, J. Zwanziger, A. Bajorska, and H. L. Yoos
Improved Asthma Care After Enrollment in the State Children's Health Insurance Program in New York
Pediatrics, February 1, 2006; 117(2): 486 - 496.
[Abstract] [Full Text] [PDF]


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Med Care Res RevHome page
J. Beich, D. P. Scanlon, J. Ulbrecht, E. W. Ford, and I. A. Ibrahim
The Role of Disease Management in Pay-for-Performance Programs for Improving the Care of Chronically Ill Patients
Med Care Res Rev, February 1, 2006; 63(1_suppl): 96S - 116S.
[Abstract] [PDF]


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Ann Fam MedHome page
S. J. Spann, P. A. Nutting, J. M. Galliher, K. A. Peterson, V. N. Pavlik, L. M. Dickinson, and R. J. Volk
Management of Type 2 Diabetes in the Primary Care Setting: A Practice-Based Research Network Study
Ann. Fam. Med, January 1, 2006; 4(1): 23 - 31.
[Abstract] [Full Text] [PDF]


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Health Aff (Millwood)Home page
N. Super
From Capitation To Fee-For-Service In Cincinnati: A Physician Group Responds To A Changing Marketplace
Health Aff., January 1, 2006; 25(1): 219 - 225.
[Abstract] [Full Text] [PDF]


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Chronic IllnessHome page
H. R. Holman
Chronic disease and the healthcare crisis
Chronic Illness, December 1, 2005; 1(4): 265 - 274.
[PDF]