Académique Documents
Professionnel Documents
Culture Documents
Pioneered by Edward H.
Wagner, MD, MPH and
colleagues at MacColl
Institute for Healthcare
Innovation at Group Health
Cooperative of Puget
Sound, Seattle Washington*
Supported by Robert Wood
Johnson Foundation**
*Wagner, E.H. (1998). Chronic disease management. What will it take to improve care for chronic
illness? Effective Clinical Practice, 1, 2-4.
**Improving Chronic illness Care (ICIC) is a national program supported by Robert Wood Johnson
Foundation with direction and technical assistance by Group Health Cooperative’s MacColl
Institute for Healthcare Innovation.
Chronic Care Management Premise
Right Thing
Right Patient
Right Time
Chronic Care Management Model
Informed, Prepared,
Activated Productive Interactions Proactive
Patient Practice Team
Patients participate in
effective community
programs
Form partnerships to fill
gaps in needed
services and avoid
duplicating efforts
Advocate for policies to
improve patient care
Health System – Organization of Care
Daily practice of
evidence-based care
Share clinical guidelines
and information with
patients*
Provide professional
education
Integrate specialty and
primary care
Comprehensive
system change
Targeting
Case
management
Primary Care Delivery System
Traditional
Provide acute care
Diagnostic and laboratory
services
Treatment of signs and
symptoms
Prescriptions
Brief education
Short appointments
Patient-initiated follow-up
Delivery System Redesign
Traditional Reconfigured
Provide acute care Developed processes for CD
Diagnostic and Incentives for making
laboratory Services changes
Treatment of signs and Extensive patient education
symptoms to increase patient’s
Prescriptions confidence and skills
Brief education Provider-initiated
Short appointments appointments and follow-up
Patient-initiated follow- Evidence-based guidelines
up and provider interaction
Information Systems
Targeting Approach
Finland 56%
Austria 55%
Germany 48%
Source: Harris Interactive Inc.
Belgium 42% (2002, August 8). European
physicians especially in
Italy 37% Sweden, Netherlands and
Ireland 28% Denmark, lead U.S. in use of
electronic medical records.
Greece 17% HealthCare News, 2(16), 1-3.