Chronic diseases have largely replaced acute illness as the major driver of health care costs in the United States.1  However, most medical practices are organized along the transactional model established for treatment of acute illness, in which a single office visit is used to diagnose and treat an illness or injury.  Under this model, chronic illnesses are often treated as a succession of individual episodes, where each patient visit consists of an evaluation of the current status and, if needed, a new or altered treatment.

The difficulty with this model is that, unlike an acute illness, the chronic disease does not resolve, and treatment is often continuous rather than a short-term event.  Also, much of the care is the responsibility of the patient and may include some life style changes (dietary changes, smoking cessation, weight loss, exercise programs, self-medication, and even self-testing such as blood glucose monitoring for those with diabetes.  These aspects of chronic disease management are often not easily incorporated into the typical transactional office visit.

An approach to correcting this is found in the Chronic Care Model, as originally described by Wagner.2  This model calls for both community resources and changes in the organization of the health care system.  Accumulated evidence suggests that use of the chronic care model leads to improved patient care and better health outcomes,3 and can be cost effective.4  While both community resources and system organization are important, this article will only consider the four pillars of the chronic care model that impact the health care delivery system.  Although full implementation of the chronic care model involves a macro approach involving the entire delivery system and the community, many of the features can be implemented in small practices as well as large institutions, and this will be our primary focus.

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