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

Models of Complex Care Management: LEAP Webinar Series #2

Multiple chronic illnesses, combined with co-existing mental/behavioral health problems, along with frailty and functional limitations pose great challenges to the work of the busy primary care team.  The “Models of Complex Care Management” webinar was recorded in January 2014 and features the work of LEAP sites in Maine, Louisiana, Texas and West Virginia. This conversation asks how to build a system that supports the care of this population? How do we identify these patients?

Changing the Culture of Care in Your Community: LEAP Webinar Series #1

First in a series of six webinars recorded for our PCT-LEAP initiative, “Changing the Culture of Care in Your Community” showcases LEAP sites that are change agents in their communities even beyond their patient population, as well as doing the work of addressing the social determinants of health in a number of venues.   We discuss the health care provider and team role in population health, and ask the question:  how do you build and sustain community partnerships that transform both health care prac

Health Literate Care Model

Health Literate Care Model

When a health care organization adopts the Health Literate Care Model, health literacy becomes embedded into all aspects of planning and operations.  View and download the Health Literate Care Model, co-authored by Michael Parchman

Citation:  Koh, H.; Brach, C.; Harris, L.M.; and Parchman, M.L. (2013) “A Proposed ‘Health Literate Care Model Would Constitute A Systems Approach to Improving Patients’ Engagement in Care.” Health Affairs. No. 2 (357-367).

Accelerating Regulatory Progress in Multi-Institutional Research

MacColl Center Business Manager Sherry Lauf and Senior Program Manager Leah Tuzzio co-authored this manuscript highlighting three case studies in which research, regulatory, and administrative teams developed and employed innovative approaches to secure and maintain Institutional Review Board approvals, enable data sharing, and expedite sub-award issuance and execution.

Nurse navigators help Group Health patients with cancer

Watch this YouTube video to learn more about the Group Health Nurse Navigator study, which resulted in improved patient experience and reduced problems in care.  Study co-author Ed Wagner comments.

Nurse navigators in early cancer care: a randomized, controlled trial.

The Nurse Navigator study set out to determine if a nurse navigator intervention improves quality of life and patient experience in newly-diagnosed patients.  Learn more about this randomized controlled trial in a paper co-authored by Ed Wagner.  Group Health was so impressed with this work that it incorporated an oncology nurse navigator into usual care for women newly diagnosed with breast cancer at its Capitol Hill campus—even before the research was published.

Self-management: Enabling and empowering patients living with cancer as a chronic illness.

People with cancer are living longer, and their cancer may be managed as a chronic illness due to recent improvements in the early detection, diagnosis, and treatment.  Read this article, co-authored by Ed Wagner, that proposes a model of care that oncology practices can use to enable and empower patients and families.

 

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