Many patients now live with two or more chronic conditions

Due to the growing burden of chronic disease, our work increasingly involves looking for ways to support providers caring for patients who are managing several chronic diseases.  We are collaborating with AHRQ through its Multiple Chronic Conditions Research Network to understand interventions of the most benefit to complex patients.

We offer a proven strategy to help guide health systems change

The Chronic Care Model (CCM) provides an evidence-based framework to guide systems change.  More than 15 years after our development and dissemination of this framework via the Improving Chronic Illness Care program, the CCM continues to be utilized by health care organizations worldwide.

Our tools measure patient and provider experience

Our survey instruments were developed to be practical, readily-available and adaptable tools to help teams improve care for chronic illness -- but they've also been implemented for research purposes around the world.  The Assessment of Chronic Illness Care (ACIC) addresses care at the community, organization, practice and patient levels, and the Patient Assessment of Chronic Illness Care (PACIC) measures specific actions or qualities of care, congruent with the CCM, that patients report they have experienced in the delivery system.

Related Resources

Ed Wagner on Caring for Complex Patients: BRIDGES Conference 2014 Keynote

BRIDGES Conference 2014: Ed Wagner Keynote Talk

Building Bridges to Integrate Care (BRIDGES) is a Toronto-based incubator for innovative models to integrate care across the continuum and across disciplines for people with complex chronic disease. Watch this video to learn more about Ed Wagner's thoughts about the challenges of caring for complex patients, including current lack of evidence for creating clinical guidelines, the complications of multiple medications, providers and services, and the lack of coordination between physicians, services and agencies.

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