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The ten characteristics of the high-performing chronic care system

  • Chris Ham (a1)
Abstract

The purpose of this paper is to describe the characteristics of the high-performing chronic care system and the four implementation strategies needed to achieve such a system. The paper starts with a description of the Chronic Care Model and summarises evidence on its impact. This is followed by a review of international evidence on gaps in the quality of chronic care. These gaps suggest that, useful and influential as the Chronic Care Model is, more is needed to help health care decision makers bring about the reorientation required to meet the needs of populations in which chronic diseases predominate. The second half of the paper therefore sets out the ten characteristics and four implementation strategies required to achieve a high-performing chronic care system. In doing so, it provides practical guidance to policy makers and health care leaders on the most promising strategies for improving the provision of chronic care, drawing on evidence from the experience of England, New Zealand and USA.

Copyright
Corresponding author
Correspondence to: Chris Ham, Professor of Health Policy and Management, Health Services Management Centre, University of Birmingham, 40 Edgbaston Park Road, Birmingham B15 2RT, UK. Email: c.j.ham@bham.ac.uk
References
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Ashton, C., Souchek, J., Petersen, N., Menke, T., Collins, T., Kizer, K., Wright, S.Wray, N. (2003), ‘Hospital use and survival among veterans affairs beneficiaries’, New England Journal of Medicine, 349: 16371646.
Billings, J., Dixon, J., Mijanovich, T.Wennberg, D. (2006), ‘Case finding of patients at risk of readmission to hospital: development of algorithm to identify high risk patients’, British Medical Journal, 333: 327330.
Boaden, R., Dusheiko, M., Gravelle, H., Parker, S., Pickard, S., Roland, M., Sargent, P.Sheaff, R. (2006), Evaluation of the Evercare Approach to Case Management: Final Report, Manchester: National Primary Care Research and Development Centre, University of Manchester.
Bodenheimer, T. (2008), ‘Coordinating care – a perilous journey through the health care system’, New England Journal of Medicine, 358: 10641070.
Bodenheimer, T., Wagner, E.Grumbach, K. (2002), ‘Improving primary care for patients with chronic illness. The Chronic Care Model, Part 2’, Journal of the American Medical Association, 288: 19091914.
Campbell, S., Reeves, D., Kontopantelis, E., Middleton, E., Sibblad, B.Roland, M. (2007), ‘Quality of primary care in England with the introduction of pay for performance’, New England Journal of Medicine, 357: 181190.
Centers for Disease Control and Prevention, Chronic Disease Prevention (2007), Retrieved 11 July 2009, http://www.cdc.gov/NCCDPHP
Congressional Budget Office (2004), An Analysis of the Literature on Disease Management Programmes, CBO: Washington, DC.
Crosson, F. J. (2003), ‘Kaiser Permanente: a propensity for partnership’, British Medical Journal, 326: 654.
Darkins, A.. (2007), ‘The Use of Assistive Technologies by Patients at Home in Improving Care Coordination’, Paper prepared for The Commonwealth Fund and The Nuffield Trust 8th International Meeting on Quality of Health Care. Pennyhill Park, Surrey, UK.
Dixon, J., Lewis, R., Rosen, R., Finlayson, B.Gray, D. (2004), Managing Chronic Disease: What Can We Learn From the US Experience, London: King’s Fund.
Doran, T., Fullwood, C., Gravelle, H., Reeves, D., Kontopantelis, E., Hiroeh, U.Roland, M. (2006), ‘Pay-for-performance in family practices in the United Kingdom’, New England Journal of Medicine, 355: 375384.
Glasgow, R., Orleans, T., Wagner, E., Curry, S.Solberg, L. (2001), ‘Does the Chronic Care Model serve also as a template for improving prevention?’, The Milbank Quarterly, 79(4): 579612.
Grumbach, K.Bodenheimer, T. (2004), ‘Can health care teams improve primary care practice?’, Journal of the American Medical Association, 291: 12461251.
Hung, D., Rundall, T., Tallia, A., Cohen, D., Halpin, H.Crabtree, B. (2007), ‘Rethinking prevention in primary care: applying the Chronic Care Model to address health risk behaviours’, The Milbank Quarterly, 85(1): 6991.
Institute of Medicine (2001), Crossing the Quality Chasm, Washington, DC: National Academy Press.
Jha, A., Perlin, J., Kizer, K.Dudley, R. (2003), ‘Effect of the transformation of the Veterans Health care system on the quality of care’, New England Journal of Medicine, 348: 22182227.
Kane, R., Priester, R.Totten, A. (2005), Meeting the Challenge of Chronic Illness, Baltimore: The Johns Hopkins University Press.
Kennedy, A., et al. (2007), ‘The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial’, Journal of Epidemiology and Community Health, 61(3): 254261.
Kerr, E.Fleming, B. (2007), ‘Making performance indicators work: experiences of US Veterans Health Administration’, British Medical Journal, 335: 971973.
Lohr, S. (2004), ‘Is Kaiser the future of American health care?’, New York Times, 31 October.
Longman, P. (2005), ‘The best care anywhere’, The Washington Monthly, January/February.
Lorig, K., Seleznick, M., Lubeck, D., Ung, E., Chastain, R. L.Holman, H. R. (1989), ‘The beneficial outcomes of the arthritis self-management course are not adequately explained by behaviour change’, Arthritis and Rheumatism, 32: 9195.
McWilliams, J. M., Meara, E., Zaslavsky, A. M.Ayanian, J. Z. (2007), ‘Health of previously uninsured adults after acquiring Medicare coverage’, Journal of the American Medical Association, 298(24): 28862894.
National Health Committee (2007), Meeting the Needs of People with Chronic Conditions, Wellington: National Advisory Committee on Health and Disability.
National Health Priority Action Council (2006), National Chronic Disease Strategy, Canberra: Australian Government Department of Health and Ageing.
Newhouse, J. and the Insurance Experiment Group (1993), Free for All? Lessons from the RAND Health Insurance Experiment, Cambridge: Harvard University Press.
Newman, S., Steed, L.Mulligan, K. (2004), ‘Self-management interventions for chronic illness’, The Lancet, 363: 15231537.
Oliver, A. (2007), ‘The Veterans Health Administration: an American success story?’, The Milbank Quarterly, 85: 535.
Porter, M.Teisberg, E. (2006), Redefining Health Care, Cambridge: Harvard Business School Press.
Olshansky, S., Passaro, D., Hershow, R., Layden, J., Carnes, B., Brody, J., Hayflick, L., Butler, R., Allison, D.Ludwig, D. (2005), ‘A potential decline in life expectancy in the United States in the 21st century’, New England Journal of Medicine, 352: 11381145.
Pearson, M. L., Wu, S. Y., Schaefer, J., Bonomi, A. E., Shortell, S. M., Mendell, P. J., Marsteller, J. A., Louis, T. A., Rosen, M.Keeler, E. B. (2005), ‘Assessing the implementation of the Chronic Care Model in quality improvement collaboratives’, Health Services Research, 40(4): 978996.
Renders, C., Valk, G., Griffin, S., Wagner, E., van Eijk, J.Assendelft, W. (2001), ‘Interventions to improve the management of diabetes in primary care, outpatient, and community settings’, Diabetes Care, 24: 18211833.
Schoen, C., Osborn, R., Huynh, P., Doty, M., Peugh, J.Zapert, K. (2006), ‘On the front line of care: primary care doctors’ office systems, experiences and views in seven countries’, Health Affairs, 25: w555w571.
Schoen, C., Osborn, R., Doty, M., Bishop, M., Peugh, J.Murukutla, N. (2007), ‘Toward higher-performance health systems: adults’ health care experiences in seven countries, 2007’, Health Affairs, 26(6): w717w734.
Singh, D. (2005a), Transforming Chronic Care: Evidence about Improving Care for People with Long-Term Conditions, Birmingham: Health Services Management Centre, University of Birmingham.
Singh, D. (2005b), Which Staff Improve Care for People with Long Term Conditions?, Birmingham: Health Services Management Centre, University of Birmingham.
Singh, D.Ham, C. (2006), Improving Care for People with Long-Term Conditions: A Review of UK and International Frameworks, Birmingham: Health Services Management Centre, University of Birmingham, and NHS Institute for Innovation and Improvement.
Sobel, D. (1995), ‘Rethinking medicine: improving health outcomes with cost-effective psychosocial interventions’, Psychosomatic Medicine, 57: 234244.
Starfield, B., Lemke, K., Bernhardt, T., Foldes, S., Forrest, C.Weiner, J. (2003), ‘Comorbidity: implications for the importance of primary care in ‘case’ management’, Annals of Family Medicine, 1: 814.
Starfield, B., Shi, L.Mackino, J. (2005), ‘Contribution of primary care to health systems and health’, The Milbank Quarterly, 83: 457502.
The Commonwealth Fund (2006), Framework for the High Performance Health System in the United States, New York: The Commonwealth Fund.
Tsai, A., Morton, S., Mangione, C.Keeler, E. (2005), ‘A meta-analysis of interventions to improve care for chronic illnesses’, The American Journal of Managed Care, 11: 478488.
Wagner, E. (1998), ‘Chronic disease management: what will it take to improve care for chronic illness?’, Effective Clinical Practice, 1: 24.
Wolff, J., Starfield, B.Anderson, G. (2002), ‘Prevalence, expenditures, and complications of multiple chronic conditions in the elderly’, Archives of Internal Medicine, 162: 22692276.
World Health Organisation Europe (2006), Gaining Health: The European Strategy for the Prevention and Control of Noncommunicable Diseases, Copenhagen: WHO Regional Office for Europe.
World Health Organisation (2005), Preventing Chronic Diseases: A Vital Investment, Geneva: WHO.
Zwar, A., Harris, N. M., Griffiths, R., Roland, M., Dennis, S., Powell Davies, G.Hasan, I. (2006), A Systematic Review of Chronic Disease Management, Canberra: Australian Primary Health Care Research Institute.
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Health Economics, Policy and Law
  • ISSN: 1744-1331
  • EISSN: 1744-134X
  • URL: /core/journals/health-economics-policy-and-law
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