INNOVATIONS INPRIMARY CARE

Improving Primary Care for PatientsWith Chronic IllnessThomas Bodenheimer, MDEdward H. Wagner, MD, MPHKevin Grumbach, MD

MR SUGARMAN, A 64-YEAR-old patient with diabetes,comes for his 15-minute visit

with Dr Madden. After evaluating MrSugarman’s acutely painful knee andtreating his gastroesophageal reflux dis-ease, Dr Madden has 3 minutes left toassess diabetic control. Having fruit-lessly searched through Mr Sugar-man’s medical records to find the lasteye examination results and hemoglo-bin A1c (HbA1c) and lipid levels, Dr Mad-den gives up in frustration and sched-ules another visit during her day off tomanage Mr Sugarman’s diabetes. MrSugarman does not keep a log of hishome glucose determinations.

Ms Feliz arrives for her planned dia-betes-management visit. At a previousacute care visit, she discussed her kneepain and gastroesophageal reflux withDr Newman. Ms Feliz, as taught in herself-management class, hands her homeglucose record to the medical assistant,who scans it into the electronic medi-cal record, reviews with Ms Feliz the re-minder pop-up message, refers her foran eye examination and test of urine mi-croalbumin levels, and prints for Ms Fe-liz and Dr Newman a graph showing thelast 2 years of her HbA1c (normal) andlow-density lipoprotein cholesterol(LDL-C) (elevated) results. Dr New-man briefly discusses with Ms Feliz anaction plan to address hyperlipidemiaand arranges 2 visits: 1 to the pharma-cist, who adjusts Ms Feliz’s medicationdoses according to a practice guideline–based protocol, and 1 to the nutrition-ist to discuss low-fat diet options.

One hundred million persons in theUnited States have at least 1 chroniccondition. Half of these individuals havemore than 1 chronic illness. Eighty-eight percent of people aged 65 yearsor older have 1 or more chronic ill-nesses, and one quarter of these have4 or more conditions. Chronic illnessaccounts for three quarters of total na-tional health care expenditures.1,2

This article is the second in the seriesInnovations in Primary Care. The ini-tial article3 summarized disturbing dataon chronic illness care. The majority ofpatientswithhypertension,4 diabetes,5 to-bacco addiction,6 hyperlipidemia,7 con-gestive heart failure,8 chronic atrial fi-brillation,9 asthma,10 and depression11 areinadequately treated. Redesign of pri-mary care has been proposed to close thequality chasm between current prac-tices and optimal standards.12 How sucha redesign might be accomplished is thesubject of this 2-part article.

Tyranny of the UrgentWhat is behind the deficiencies inchronic disease care? Frequently, theacute symptoms and concerns of the pa-tient crowd out the less urgent need tobring chronic illness under optimalmanagement. Clinicians—as in the vi-

gnette describing Dr Madden—routinely experience this tyranny of theurgent.13

Under a system designed for acuterather than chronic care, patients are notadequately taught to care for their ownillnesses. Visits are brief and little plan-ning takes place to ensure that acute andchronic needs are addressed. Lacking isa division of labor that would allow non-physician personnel to take greater re-sponsibility in chronic care manage-ment. Too often, caring for chronicillness features an uninformed passivepatient interacting with an unpreparedpractice team, resulting in frustrating, in-adequate encounters.13

Chronic Care ModelOne of us (E.H.W.) has developed amodel for primary care of patients withchronic illness—a guide to be used in

Author Affiliations: Family and Community Medi-cine, University of California, San Francisco (Drs Boden-heimer and Grumbach); and MacColl Institute forHealthcare Innovation, Center for Health Studies,Group Health Cooperative of Puget Sound, Wash(Dr Wagner).Corresponding Author: Thomas Bodenheimer, MD,San Francisco General Hospital, Ward 83, 1001 PotreroAve, San Francisco, CA 94110 (e-mail: tbodie@earthlink.net).Reprints are not available from the author.Innovations in Primary Care Section Editor:Drummond Rennie, MD, Deputy Editor, JAMA.

The chronic care model is a guide to higher-quality chronic illness manage-ment within primary care. The model predicts that improvement in its 6 in-terrelated components—self-management support, clinical information sys-tems, delivery system redesign, decision support, health care organization,and community resources—can produce system reform in which informed,activated patients interact with prepared, proactive practice teams. Case stud-ies are provided describing how components of the chronic care model havebeen implemented in the primary care practices of 4 health care organizations.JAMA. 2002;288:1775-1779 www.jama.com

©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, October 9, 2002—Vol 288, No. 14 1775

at University of California - San Francisco on January 31, 2012jama.ama-assn.orgDownloaded from

developing effective chronic care. Thechronic care model was derived fromefforts to improve chronic illness man-agement at Group Health Cooperativeof Puget Sound in Washington, from lit-erature reviews, and from suggestionsof an advisory panel to Group Health’sMacColl Institute for Healthcare Inno-vation. The model does not offer a quickand easy fix; it is a multidimensionalsolution to a complex problem.

Because the majority of chronic ill-ness care is performed within the pri-mary care setting3 and because primarycare physicians spend a considerableamount of their time treating chronic ill-ness, the chronic care model consti-tutes a major rethinking of primary carepractice, as pictured in the opening vi-gnette about Dr Newman.

Chronic care takes place within 3overlapping galaxies: (1) the entire com-munity, with its myriad resources andnumerous public and private policies;(2) the health care system, including itspayment structures; and (3) the pro-vider organization, whether an inte-grated delivery system, a small clinic, ora loose network of physician practices.

Within this trigalactic universe, theworkings of which may help or hinderoptimal chronic care, the chronic caremodel identifies 6 essential elements:community resources and policies,health care organization, self-manage-ment support,delivery systemdesign,de-cision support, and clinical informa-tion systems.14,15 What are these 6 pillarsof the chronic care edifice?

Community Resources and PoliciesTo improve chronic care, provider or-ganizations need linkages with com-munity-based resources, eg, exerciseprograms, senior centers, and self-help groups. Community linkages—for example, with hospitals offering pa-tient education classes or home careagencies providing case managers—are especially helpful for small physi-cian offices with limited resources.

Health Care OrganizationThe structure, goals, and values of aprovider organization and its relation-

ships with purchasers, insurers, andother providers form the foundationupon which the remaining 4 compo-nents of the chronic care model rest. Ifan organization’s goals and leaders donot view chronic care as a priority, in-novation will not take place. The re-imbursement environment of a pro-vider organization has a major impacton chronic care improvements, whichare more likely to survive throughoutthe long term if they increase rev-enues or reduce expenses. If purchas-ers and insurers fail to reward chroniccare quality, improvements are diffi-cult to sustain.

Self-management SupportFor chronic conditions, patients them-selves become the principal care-givers.16 People live with chronic ill-ness for many years; management ofthese illnesses can be taught to most pa-tients, and substantial segments of thatmanagement—diet, exercise, self-measurement (eg, using glucometers orbathroom scales), and medication use—are under the direct control of the pa-tient. Self-management support in-volves collaboratively helping patientsand their families acquire the skills andconfidence to manage their chronic ill-ness, providing self-management tools(eg, blood pressure cuffs, glucom-eters, diets, and referrals to commu-nity resources), and routinely assess-ing problems and accomplishments.

Delivery System DesignThe structure of medical practice mustbe altered, creating practice teams witha clear division of labor and separat-ing acute care from the planned man-agement of chronic conditions. Physi-cians treat patients with acute problems,intervene in stubbornly difficult chroniccases, and train team members. Non-physician personnel are trained to sup-port patient self-management, ar-range for routine periodic tasks (eg,laboratory tests for diabetic patients, eyeexaminations, and foot examina-tions), and ensure appropriate follow-up. Planned visits are an important fea-ture of practice redesign.

Decision SupportEvidence-based clinical practice guide-lines provide standards for optimalchronic care and should be integratedinto daily practice through reminders.Ideally, specialist expertise is a meretelephone call away and does not al-ways require full specialty referral.Guidelines are reinforced by physi-cian “champions” leading educationalsessions for practice teams.

Clinical Information SystemsComputerized information has 3 im-portant roles: (1) as reminder systemsthat help primary care teams complywith practice guidelines; (2) as feed-back to physicians, showing how eachis performing on chronic illness mea-sures such as HbA1c and lipid levels; and(3) as registries for planning indi-vidual patient care and conductingpopulation-based care.

Registries, a central feature of thechronic care model, are lists of all pa-tients with a particular chronic condi-tion on an organization’s or physi-cian’s panel. Take diabetes, for example.Data for patients with a diabetes-related International Classification ofDiseases, Ninth Revision (ICD-9) code,diabetic prescription, or laboratory testresult indicating diabetes are enteredelectronically into the diabetic regis-try. Laboratory values—HbA1c, LDL-C,and urine microalbumin—automati-cally flow to the registry. Ideally, eyeand foot examinations and blood pres-sure measurements are also entered.The registry may feed into a reminderpop-up message on the electronic medi-cal record, which flags laboratory workor examinations not performed accord-ing to schedule. With paper charts, re-minder sheets can be printed for eachvisit by the diabetic patient. As a popu-lation tool, registry data can be elec-tronically sorted to identify and con-tact patients with elevated HbA1c levelsor those lacking up-to-date eye exami-nation results.

The 6 components of the chronic caremodel are interdependent, buildingupon one another. Community re-sources—for example, exercise pro-

INNOVATIONS IN PRIMARY CARE

1776 JAMA, October 9, 2002—Vol 288, No. 14 (Reprinted) ©2002 American Medical Association. All rights reserved.

at University of California - San Francisco on January 31, 2012jama.ama-assn.orgDownloaded from

grams and peer support groups—helppatients acquire self-management skills.Delivery system redesign, the forma-tion of primary care teams with a divi-sion of labor, is essential to teach self-management because physicians do nothave the time and may not be prop-erly trained for this activity. For chronicdisease registries to be successful, re-designing delivery systems is neces-sary so that 1 member of a primary careteam is responsible for working the reg-istry. Clinical practice guidelines, a keydecision-support tool, provide the evi-dence upon which physician feedbackdata and reminder systems are based.Chronic care model elements are un-likely to be introduced or maintainedwithout an organizational environ-ment featuring innovative leadershipand favorable finances.

As its ultimate goal, the chronic caremodel envisions an informed, acti-vated patient interacting with a pre-pared, proactive practice team, result-ing in high-quality, satisfying encountersand improved outcomes.17

Is the model a utopian concept, im-possible to implement in the rough-and-tumble world of primary care? A num-ber of organizations have attempted tointroduce the chronic care model. Somehave enjoyed success. Others suc-ceeded but were unable to sustain theimprovements. The chronic care modelbegan at a handful of integrated deliv-ery systems, most notably LovelaceHealth Systems in Albuquerque andGroup Health Cooperative of PugetSound in Seattle.18-20 Projects to spreadthe model to other provider organiza-tions are under way, with the supportof the Robert Wood Johnson Founda-tion’s project Improving Chronic Ill-ness Care (ICIC)21 and the Institute forHealthcare Improvement (IHI).

Implementing the ChronicCare ModelThe chronic care model is not an ab-stract theory but a concrete guide to im-proving practice. The case studies pre-sented here were chosen because theyinvolve private medical practices, 2 in-tegrated delivery systems, and a com-

munity health center and because eachorganization has implemented a mix-ture of chronic care model elements(TABLE). In each case, the organiza-tion’s own evaluation suggests thatimplementation of the model im-proved patient care. Although these in-ternal measurements do not meet rig-orous standards of evidence, part 2 ofthis article describes published evi-dence on the effectiveness of chroniccare model components.

Premier Health PartnersIn 1998, Premier Health Partners joinedthe diabetes collaborative, a joint ef-fort of ICIC and the IHI. Located inDayton, Ohio, Premier Health Part-ners is a health system based on the tra-ditional private practice model. Onehundred physicians working in 36 pri-vate offices make up Premier’s pri-mary physician network. Starting withone physician and gradually adding allprimary care practices, Premier used thechronic care model to improve diabe-tes care. By 2001, for the entire pri-mary care network, the proportion ofdiabetic patients with HbA1c levels be-low 7% had risen from 42% to 70%.Similar improvements were recordedfor foot examination results, urine mi-croalbumin levels, and use of angio-tensin-converting enzyme inhibitors.

Decision support is provided throughpractice guidelines, academic detail-ing, and a toolkit of printed materialsthat incorporate practice guidelines intothe day-to-day care of diabetic pa-tients. Self-management support in-cludes individual and group classes andflowcharts on which patients record

their own laboratory test results. De-livery-system redesign began with thedevelopment of practice teams in whichphysicians and nurses work together tomonitor diabetes flow sheets. PremierHealth Partners has achieved its im-proved diabetes care with a rudimen-tary but effective information system:medical-record reviews in each pri-mary care practice generate physician-specific data on diabetes measures thatare circulated unblinded to all physi-cians. Over time, these data have stimu-lated physicians with poor perfor-mance to improve. The informationsystem will soon be generating physi-cian and patient reminders.

The diabetes program is financiallysupported by Premier Health Partners.One insurer has agreed to reimburse of-fice-based diabetes education, and an-other is making a yearly bonus pay-ment if diabetes performance exceeds anagreed-upon benchmark. Premier isplanning to extend its chronic illness im-provement program to cardiac diseaseand asthma and to develop an activechronic disease registry.

HealthPartners Medical GroupLike Premier Health Partners, Health-Partners Medical Group (HPMG) joinedthe ICIC-IHI diabetes collaborative in1998. An integrated delivery systembased in Minneapolis, HPMG imple-mented 4 components of the chroniccare model. Patient self-managementtraining is performed by diabetes re-source nurses at each clinic. Decisionsupport includes practice guidelines, dia-betes update conferences, and a diabe-tes support team. The information sys-

Table. Case Studies of Chronic Care Model Implementation

Name Type of OrganizationMain Chronic Care ModelComponents Introduced

Premier Health Partners Network of private practices Decision-support tools and physicianperformance feedback

HealthPartners MedicalGroup

Integrated delivery system Disease registry, case managementof high-risk patients, primary careteams

Clinica Campesina Community health center Self-management training, diseaseregistry with reminder system,primary care teams

Kaiser-PermanenteNorthern California

Integrated delivery system Intensive treatment of high-riskpatients

INNOVATIONS IN PRIMARY CARE

©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, October 9, 2002—Vol 288, No. 14 1777

at University of California - San Francisco on January 31, 2012jama.ama-assn.orgDownloaded from

tem has created a diabetes registry usedto risk-stratify patients, create re-minder prompts, and generate physi-cian-specific performance reports. Theregistry provides each physician with aquarterly at-risk list that prioritizes pa-tients according to HbA1c and LDL-C lev-els and presence of coronary artery dis-ease. These quarterly reports alsoprovide graphs showing physician andclinic performance on HbA1c and LDL-Cmeasures. Delivery system redesign in-volves primary care teams, group dia-betes visits, and case management for pa-tients designated by the at-risk list torequire more intensive management.22

From January to December 1999, thepercentage of HPMG diabetic patientswith HbA1c levels below 8% increasedfrom 60.5% to 68.3%, and the percent-age with HbA1c levels of 10% or higherfell from 10.3% to 7.2%. Mean HbA1c

dropped from 7.86% to 7.47% (P<.001).Similar improvements were seen inLDL-C levels.22

Clinica CampesinaMore than 700 community health cen-ters operate in the United States, serv-ing 9.6 million patients at thousands ofsites. Community health centers oper-ate with funds from the federal Bureauof Primary Health Care, Medicare, Med-icaid, and state health departments.Eighty-six percent of community healthcenter patients live below 200% of thefederal poverty line, 40% are unin-sured, and 64% are ethnic minoritieswho experience higher-than-averagerates of chronic illness.23

In 1998, the Bureau of Primary HealthCare joined the diabetes collaborative ofICIC and IHI as part of its Health Dis-parities Initiative, a concerted programaimed at eliminating racial, ethnic, andsocioeconomic disparities.24 The bu-reau funded a full-time coordinator ineach of 5 geographic clusters, and 1 com-munity health center from each clusterwas picked as the lead organization. The5 coordinators and a team from each ofthe 5 lead community health centers at-tended ICIC-IHI’s training sessions onorganizational changeandcareof chronicillness. By 2001, diabetes improvement

programs had spread from 5 to 200 clini-cal sites; in 2002, 371 community healthcenters had chronic care projects in dia-betes, cardiovascular disease, asthma, de-pression, or all 4. A leader in the initialdiabetes collaborative was ClinicaCampesina Family Health Services.

Clinica Campesina provides care to alargely uninsured Hispanic populationaround Denver, Colo. Assisted by thediabetes collaborative, Clinica Campe-sina implemented most components ofthe chronic care model, including pri-mary care teams with a division of la-bor, a diabetes registry (using a rudi-mentary information system requiringclinic staff to input data), physician re-minders, diabetes group visits (deliv-ery system redesign), and activation ofpatients to manage their illness throughdiabetes education and collaborative set-ting of diabetes treatment goals duringeach clinic visit. Patients are providedwith self-management plans allowingthem to choose self-improvement goalssuch as walking a mile each day or stop-ping tobacco use. Monthly printouts ofthe registry are distributed to all physi-cians, and, to relieve physicians’ work-load, medical assistants read patients’flow sheets and make appropriate prepa-rations for needed examinations or tests.Outreach is provided to patients on theregistry who have poorly controlled ill-ness or difficulty coming to the clinic.

Clinica Campesina’s self-reported datashow that the average HbA1c level of itsdiabetic population dropped from 10.5%in October 1998 to 8.6% in March 2000.The percentage of diabetic patients withat least 2 HbA1c tests within a year rosefrom 11% in October 1998 to 71% inJune 2000. The percentage of diabetic pa-tients with self-management goalsjumped from 3% in February 1999 to65% in March 2000. The percentage ofthose having eye examinations climbedfrom 7% to 51%, and the percentage hav-ing foot examinations rose from 15% to76% in the same period.

Kaiser-PermanenteNorthern CaliforniaKaiser Health Plan and the associatedPermanente Medical Group serve 3 mil-

lion people in the northern Californiaregion. Within Kaiser-PermanenteNorthern California (KP-NC), 22% ofadult enrollees, mainly those withchronic conditions, generate 47% ofadult ambulatory visits and 74% of non-obstetric hospital days. By 1999, KP-NChad launched Chronic Care Manage-ment programs targeting diabetes, coro-nary artery disease, hyperlipidemia,asthma, and congestive heart failure.Kaiser-Permanente Northern Califor-nia invested millions of dollars in theseprograms, hoping to improve healthoutcomes and thereby create savingsthrough fewer hospitalizations andemergency department visits.

Chronic Care Management dividesKP-NC’s chronic condition populationof 400000 into 3 levels. Patients at level1 have their chronic condition under rea-sonable control and receive care throughtheir primary care team. Patients at level2 have poorly controlled conditions; forexample, diabetic patients with HbA1c

levels above 10% qualify for level 2. Level3 is composed of patients with com-plex multidiagnoses, high-use pa-tients, or both who receive case man-agement by registered nurses or medicalsocial workers within the primary careteam; because patients have multiple di-agnoses, level 3 case management is notdisease-specific.

The most far-reaching delivery sys-tem redesign involves level 2 patients,who are referred to disease-specific caremanagers who may be attached to a pri-mary care team. Care managers—nurses, health educators, pharmacists,respiratory therapists, or dietitians—exist for management of diabetes, hy-perlipidemia, asthma, and congestiveheart failure. They are responsible for alist of patients with whom they work in-tensively for a 6- to 15-month period, af-ter which, if the illness is better con-trolled, the patient returns to level 1. Caremanagers, who attend training pro-grams, update seminars, and peer groupmeetings, are mentored by disease-specific physician champions.

Adult asthma provides an example ofhow KP-NC’s Chronic Care Manage-ment programs operate. Data for asth-

INNOVATIONS IN PRIMARY CARE

1778 JAMA, October 9, 2002—Vol 288, No. 14 (Reprinted) ©2002 American Medical Association. All rights reserved.

at University of California - San Francisco on January 31, 2012jama.ama-assn.orgDownloaded from

matic adults are electronically enteredinto the asthma registry according to di-agnosis code or use of asthma medica-tions. Patients with an asthma-relatedemergency department visit, hospital-ization, or pharmacy data revealing 2prednisone bursts or an excess of asthmainhalers are designated as level 2 or highrisk and referred to an asthma care man-ager. Care managers—nurses, respira-tory therapists, or pharmacists—arrange a personal visit, including patientself-management support with trainingon use of inhalers, spacers, and peak flowmeters. Care managers can change medi-cations according to clinical protocols.Patients are taught about triggers and en-vironmental controls and how to stagethe severity of their illness. Care man-agers help patients set specific monthlygoals; for example, regular use of ste-roid inhalers or keeping the cat off thebed at night. Smokers are referred tosmoking cessation classes.

Chronic Care Management leaders areconcerned about level 1, which handles85% to 90% of KP-NC’s chronic care pa-tients (only 12% of asthmatic patientsare in level 2 at any given time). Even iflevel 2 is working well, failure to im-prove level 1 care threatens population-

wide improvement in performance mea-sures. To remedy this problem, theasthma program is planning training ses-sions for health educators on primarycare teams, physician-specific feed-back, and prompts reminding physi-cians to check peak flows, assess asthmasymptoms, review self-management careplans, and improve medication use.

The clinical information systemtracks the asthma inhaled medicationratio (anti-inflammatory canisters di-vided by anti-inflammatory plus bron-chodilator canisters). The long-termgoal (benchmark) for this ratio is for95% of primary care physicians to havea ratio higher than 0.3. From 1998 toearly 2001, according to KP-NC’s owndata, the percentage exceeding 0.3 in-creased from 52% to 79% (32% have aratio �0.5).

The information system also tracksthe percentage of asthma patients athigh risk of an acute event (those witha recent emergency department visit,hospitalization, or high volume ofasthma-related prescriptions). Thismeasure dropped from 13.5% in 1998to 9.1% in early 2001, with the bestmedical center reporting a rate of 6.5%.The long-term benchmark is 8%. From

1996 to 2000, the emergency depart-ment visit rate declined from 10 per 100persistent asthmatic patients to 4.Through registry-generated data,KP-NC determines which of its 17medical centers are performing well andcan provide assistance to centers withless adequate performance.

CONCLUSIONThese case studies illustrate how a broadvariety of practice organizations haveimplemented the chronic care model atthe primary care level. In each case, theorganizations are attempting to trans-form primary care practice from the un-tenable situation faced by Dr Madden inthe opening vignette to the idealizedworld inhabited by Dr Newman. Noneof the organizations has achieved fullimplementation of the chronic caremodel, but all have made importantstrides toward that goal.

Funding/Support: The development and testing of thechronic care model has been supported by grants fromthe Robert Wood Johnson Foundation. The researchused in writing this 2-part article was funded in partby Robert Wood Johnson Foundation grant 038253.Acknowledgment: Tracy Orleans, PhD, senior scien-tist and senior program officer at the Robert WoodJohnson Foundation, and colleagues at the MacCollInstitute for Healthcare Innovation have been invalu-able in the development of the chronic care model.

REFERENCES

1. Hoffman C, Rice D, Sung HY. Persons with chronicconditions: their prevalence and costs. JAMA. 1996;276:1473-1479.2. Wagner EH. Meeting the needs of chronically illpeople. BMJ. 2001;323:945-946.3. Grumbach K, Bodenheimer T. A primary care homefor Americans: putting the house in order. JAMA. 2002;288:889-893.4. Joint National Committee on Prevention, Detec-tion, Evaluation, and Treatment of High Blood Pres-sure. Arch Intern Med. 1997;157:2413-2446.5. Clark CM, Fradkin JE, Hiss RG, Lorenz RA, Vinicor F,Warren-Boulton E. Promoting early diagnosis and treat-ment of type 2 diabetes. JAMA. 2000;284:363-365.6. Perez-Stable EJ, Fuentes-Afflick E. Role of clini-cians in cigarette smoking prevention. West J Med.1998;169:23-29.7. McBride P, Schrott HG, Plane MB, Underbakke G,Brown RL. Primary care practice adherence to na-tional cholesterol education program guidelines for pa-tients with coronary heart disease. Arch Intern Med.1998;158:1238-1244.8. Ni H, Nauman DJ, Hershberger RE. Managed careand outcomes of hospitalization among elderly pa-tients with congestive heart failure. Arch Intern Med.1998;158:1231-1236.

9. Samsa GP, Matchar DB, Goldstein LB, et al. Qualityof anticoagulation management among patients withatrial fibrillation. Arch Intern Med. 2000;160:967-973.10. Legorreta AP, Liu X, Zaher CA, Jatulis DE. Varia-tion in managing asthma: experience at the medicalgroup level in California. Am J Manag Care. 2000;6:445-453.11. Young AS, Klap R, Sherbourne CD, Wells KB. Thequality of care for depressive and anxiety disorders inthe United States. Arch Gen Psychiatry. 2001;58:55-61.12. Institute of Medicine. Crossing the Quality Chasm:A New Health System for the 21st Century. Wash-ington, DC: National Academies Press; 2001.13. Wagner EH, Austin BT, Von Korff M. Organiz-ing care for patients with chronic illness. Milbank Q.1996;74:511-544.14. Wagner EH. Chronic disease management: whatwill it take to improve care for chronic illness? Eff ClinPract. 1998;1:2-4.15. Wagner EH, Austin BT, Davis C, Hindmarsh M,Schaefer J, Bonomi A. Improving chronic illness care:translating evidence into action. Health Aff (Mill-wood). 2001;20:64-78.16. Lorig K. Self-management of chronic illness: amodel for the future. Generations. 1993;17:11-14.

17. Wagner EH, Davis C, Schaefer J, Von Korff M,Austin B. A survey of leading chronic disease man-agement programs: are they consistent with the lit-erature? Manag Care Q. 1999;7:56-66.18. Byrnes J. Does disease management really work?the Lovelace Health Systems experience. Dis Manag.1998;1:39-53.19. Stuart ME. Successful implementation of a guide-line program for the rational use of lipid-lowering drugs.HMO Pract. 1991;5:198-204.20. Handley MR, Stuart ME, Kirz HL. An evidence-based approach to evaluating and improving clinicalpractice: implementing practice guidelines. HMO Pract.1994;8:75-83.21. Robert Wood Johnson Foundation. Improvingchronic illness care. Available at: http://www.improvingchroniccare.org. Accessibility verified July11, 2002.22. Sperl-Hillen J, O’Connor PJ, Carlson RR, et al. Im-proving diabetes care in a large health care system. JtComm J Qual Improv. 2000;26:615-622.23. Health, United States, 2000. Washington, DC: USDept of Health and Human Services; 2000.24. Wagner EH. Quality improvement in chronic ill-ness care: a collaborative approach. Jt Comm J QualImprov. 2001;27:63-80.

INNOVATIONS IN PRIMARY CARE

©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, October 9, 2002—Vol 288, No. 14 1779

at University of California - San Francisco on January 31, 2012jama.ama-assn.orgDownloaded from