Excerpted from "Organizing Care for Patients With Chronic Illness Revisited", August 2019, Edward H. Wagner, Early View, Milbank Quarterly Classic.

The impetus for our 1996 Milbank Quarterly article “Organizing Care for Patients With Chronic Illness” (Edward H. Wagner, Brian T. Austin, Michael Von Korff) was the disturbing evidence of inadequate care among patients with common chronic illnesses. Why were well-trained, hard-working clinicians (like us) unable to deliver proven services reliably or achieve targeted levels of blood pressure, HbA1c, or other disease control indicators for our patients? Our reliance on sporadic, physician-dominated office visits with competing agendas and multipound paper records wasn’t doing the job.

Pioneers in health care quality improvement, such as Don Berwick and Paul Batalden, helped us to see that we were working in poorly designed systems of care, which had evolved ages ago to respond to acute illnesses and injuries. In other words, our “system” for delivering care to our patients “was perfectly designed to achieve the [mediocre] results it achieves.”

We looked in the literature for changes to traditional care systems that would improve care. Three findings influenced our future course. First, the interventions that improved care and outcomes consistently fell into four categories: changes to the way care is delivered, changes to the education and support for patients, interventions to educate or remind providers, and changes to information systems.

In the model shown in Figure 1 of the Milbank Quarterly article and reprinted here, these four categories were labeled Practice Redesign, Patient Education, Expert System, and Information, respectively. Second, the relevant research almost invariably involved patients with a particular chronic disease such as diabetes or asthma. This raised a critical question—would the system changes that improved care and outcomes vary substantially from condition to condition? Our literature review strongly suggested that similar interventions in the four categories improved care across different chronic conditions. Third, further literature reviews found that more  multifaceted interventions with components from all four categories resulted in the largest improvements in care and outcomes.

Twenty-three years after publication of our Milbank article, we know much more about the design of care systems that can reliably deliver evidence-based care, engage and satisfy patients, and achieve better control of chronic diseases. Nevertheless, helping busy practices to transform into effective care systems still remains a formidable challenge. 

Read the full August 2019 commentary by Ed Wagner.