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Primary care as it is generally practiced in the U.S. isn't working, and the time is ripe for widespread adoption of the chronic care model, says Theodore Ganiats, MD, professor at the University of California, San Diego.
He cites some statistics to prove his point: 27% of hypertension is adequately controlled; 26% of patients with diabetes have their blood pressure under control; 25% of depression is treated; and 50% of patients hospitalized for congestive heart failure are readmitted within 90 days.
To help battle these numbers, the American Academy of Family Physicians (AAFP) has made management of chronic illness its Annual Clinical Focus (ACF) for 2007, which was launched with more than 35 program offerings at its Annual Scientific Assembly, held September 27–October 1 in Washington, D.C. Partners for the ACF include the American Diabetes Association, the American Heart Association, the National Heart, Lung, and Blood Institute, the Centers for Disease Control and Prevention, and the American Cancer Society.
Ganiats moderated the ACF "Chronic Care Model `Kickoff' Panel Discussion," where panelists encouraged attendees to use the chronic care model developed by internist and epidemiologist Edward Wagner, MD, MPH, director of the MacColl Institute for Healthcare Innovation in Seattle (see chart).1 Wagner's model is a road map for implementing system change within individual practices geared toward high-quality, patient-centered chronic disease care.
PERFORMANCE MEASUREMENT
As panelist Bruce Bagley, MD, puts it, the chronic care model establishes linkages between the silos of the practice and the community. Bagley is AAFP's medical director for quality improvement, and among the projects he works on is the Practice Enhancement Forum, which teaches family practices the team development, change management, project management, and leadership skills needed to incorporate the chronic care model.
Bagley says he spends half his time working with practices on new approaches to collecting performance measures, particularly around diabetes, coronary disease, and hypertension.
"We need to get away from the concept of chart audits and move toward prospective data collection as the patient moves through the office," he says.
Bagley says practices should use a comprehensive set of the same nationally accepted evidence-based measures, such as the diabetes measures approved by the National Quality Forum, the Ambulatory Quality Alliance, and the National Committee for Quality Assurance—all should be subsets of each other. He notes that AAFP's Measuring, Evaluating, and Translating Research Into Care (METRIC) program is one way family physicians can earn CME credits online for their quality improvement efforts (see "FYI").
Ganiats suggests accurate recording of values, noting that the changes he has seen over the years regard thresholds, not the measures themselves. And Stephen Spann, MD, chair of the family and community medicine department at Baylor University in Houston, recommends documenting the percentage of patients who meet whatever the current thresholds are for quality improvement.
BETWEEN-VISIT SELF-MANAGEMENT SUPPORT
Panelist Joseph Scherger, MD, MPH, director of the San Diego Center for Patient Safety, says making success real for a practice is not only about improving periodic visits, using an electronic health record (EHR), meeting guidelines at the point of care, or fulfilling other components of classic quality improvement strategies.
"It's about what takes place between your periodic visits," he says. "The secret to success is engagement," the everyday decisions a diabetes patient makes regarding his or her care, for example.
Scherger notes that the use of promotoras, or lay community health promoters who are engaged in patients' homes for regular education and follow-up, has achieved wonderful results among some of the poorest citizens in Santa Ana, Calif.
Spann agrees about the importance of self-management support, noting that the challenge is often for patients to really understand the importance of goals. He offers five steps to help a patient develop a self-management plan:
Finally, Terry McGeeney, MD, president and CEO of TransforMED, AAFP's practice redesign initiative, emphasizes the need to tap into as many of the quality-improvement strategies as possible, including EHRs, quality measures, teamwork, access to care, and collaborative care.
Scherger concedes uniting each element of the model is a complex and challenging endeavor, but contends that the key may be in a convergence of three elements: patient data, the right knowledge at the point of care, and communication and engagement with the patient.
"That triple convergence will always result in something a whole lot
better than traditional care," he says. 
Overview of the Chronic Care Model
Functional and Clinical Outcomes
The chronic care model includes each of the following
components:
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Source: AAFP ACF 2007 Management of chronic illness: Guide to implementing the chronic care model.
Footnotes
AAFP's Practice Enhancement Forum is a CME activity and quality improvement initiative that provides family physicians and their office staffs with practical tools, skills, and knowledge to implement the chronic care model in everyday practice. More information is available at www.aafp.org/pef.
More information about AAFP's METRIC program is available at www.aafp.org/online/en/home/cme/selfstudy/metric.html.
Challenging the Status Quo in Chronic Disease Care: Seven Case Studies, a report from the California HealthCare Foundation, looks at provider-based strategies outside typical disease management and the clinic-based chronic care model. It examines benefits, limitations, and policy implications of alternative approaches. Available online at www.chcf.org/topics/chronicdisease/index.cfm?itemID=125226.
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