Chronic Illness Care

Primary care plays an essential role in the frontline management of chronic illness, and health systems everywhere are looking for practical ways to improve care for people with chronic conditions. That’s why our work has long focused on creating patient-centered approaches that are built to work on the ground in primary care.

Chronic Illness Care

Why focus on transforming chronic illness care?

Our population is aging rapidly, and people with chronic conditions are living longer. Chronic conditions like diabetes, heart disease, depression, or asthma now affect nearly 150 million Americans. About half of Americans over 65 — our nation’s fastest-growing segment — have at least two chronic conditions. Living with chronic illness is costly physically, emotionally, and financially for people and communities, and accounts for hundreds of billions of dollars in health care spending every year.

A proven strategy to guide health system change

Primary care plays an essential role in supporting patients to manage their chronic illnesses, and our work has long focused on creating patient-centered approaches that are built to strengthen primary care.  In the late 1990s, with support from the Robert Wood Johnson Foundation (RWJF), Dr. Ed Wagner and team created the Chronic Care Model — an evidence-based framework to guide systems change and improve care for chronic conditions. At the heart of the Chronic Care Model is the recognition that improved health and well-being comes from the close partnership between prepared, proactive practice teams and informed, activated patients and families.  

Initial testing and development of the Chronic Care Model took place as part of our Improving Chronic Illness Care Program, a nationwide effort funded by RWJF to help primary care practices implement the Chronic Care Model by organizing technical assistance and learning collaboratives. From there we launched a national program of Health Disparities Collaboratives that eventually involved more than 500 federally qualified community health centers nationwide.

Practical tools with global reachCCM-global-translations.jpg

Now, nearly 25 years later, the Chronic Care Model has been translated into more than 30 languages and continues to be used by health care organizations worldwide to organize care for people living with chronic illness. To support the model’s implementation, we offer assessments and other tools to help measure a primary care practice’s progress toward patient-centered, evidence-based care for chronic conditions. 
Researchers have also used and adapted the Chronic Care Model to inform best practices in a variety of contexts, with thousands of citations in the medical literature.  

Our work to advance chronic illness care continues to inform important initiatives, such as the EvidenceNOW: Advancing Heart Health in Primary Care initiative funded the Agency for Healthcare Research and Quality to improve cardiovascular care outcomes by applying evidence-based strategies. Through EvidenceNOW, we led the Healthy Hearts Northwest project from 2015 to 2018 — in collaboration with the Oregon Rural Practice Research Network, the Institute of Translational Health Sciences, and 200 primary care clinics in Washington, Oregon, and Idaho.

Most recently, the Chronic Care Model was used as a foundational component of a new diabetes care program at Vayu Health, a nonprofit startup in California that serves people who have insurance through Medicaid and focuses on partnering with primary care providers at federally qualified health centers (FQHCs) to provide extra support for people with unmet medical, behavioral, and social needs. The ACT Center is partnering with Vayu to support program design, implementation, and evaluation.

Featured work in chronic illness care

Featured publications

Parchman ML, Stefanik-Guizlo K, Penfold RB, Holden E, Shah AC. Improving Diabetes Control in a Medicaid Managed Care Population With Complex Needs. Perm J. 2023 Dec 20:1-6. doi: 10.7812/TPP/23.106. Online ahead of print. Full text

Parchman ML, Stefanik-Guizlo K, Shah AC, Glaseroff A, Holden E, Bertko J, Zúñiga R. How to Identify and Support Emerging Risk Medi-Cal Members with Complex Social and Behavioral Needs: A Diabetes Case Study. California Health Care Foundation. December 2023. Full text

Wagner EH. Organizing care for patients with chronic illness revisited. Milbank Q. 2019 Sep;97(3):659-664. doi: 10.1111/1468-0009.12416. Epub 2019 Aug 19. PubMed

Coleman K, Austin BT, Brach C, Wagner EH. Evidence On The Chronic Care Model In The New Millennium. Health Aff (Millwood). 2009 Jan-Feb;28(1):75-85. doi: 10.1377/hlthaff.28.1.75. PubMed

Wagner EH. Chronic Disease Management: What Will it Take to Improve Care for Chronic Illness? Effective Clinical Practice 1998;12(4):1-3. PubMed

Wagner EH, Austin B, Von Korff M.  Improving outcomes in chronic illness. Manag Care Q 1996;4(2):12-25. PudMed