Organizing Care for Patients with Chronic Illness
Abstract
Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
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Strong patient-provider relationships have long been acknowledged as crucial for delivering high-quality, person-centred care.
“Strong patient-provider relationships have long been acknowledged as crucial for delivering high-quality, person-centred care [40–43].”
From Caregiver experiences of an integrative patient-centered digital health application for pediatric type 1 diabetes care: Findings from a pilot clinical trial (2025) · cites this paper as [42]
There is a growing body of evidence that supporting people to self-manage their health and care can lead to improvements in clinical and humanistic outcomes, reducing the economic impact of chronic disease and contributing to the sustainability of the global healthcare system.
“There is a growing body of evidence that shows supporting people to self-manage their health and care can lead to improvements in clinical and humanistic outcomes [12–18], reducing the economic impact of chronic disease and a means of contributing to the sustainability of the global healthcare system.”
From Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice (2019) · cites this paper as [14]
Similar trends have been found in existing literature in several contexts that self-management is essential to optimizing clinical and humanistic outcomes for patients with chronic conditions.
“Similar trends have been found in existing literature in several contexts that self-management is essential to optimizing clinical and humanistic outcomes for patients with chronic conditions [13, 15, 18, 152–155].”
From Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice (2019) · cites this paper as [153]
The chronic care model was initially articulated by Wagner et al.
“One such approach was initially articulated by Wagner et al as the 'chronic care model' 18 .”
From Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries (2019) · cites this paper as [18]
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- Authors
- Wagner, E. H., Austin, B. T., & Korff, M. V.
- Affiliations
- Group Health Cooperative (US)
- ORCID
- Wagner, Edward H.
- Venue
- The Milbank Quarterly
- Publisher
- JSTOR
- Published
- 1996
- Volume
- 74
- Issue
- 4
- Pages
- 511
- ISSN
- 0887-378X (ISSN-L)
- OpenAlex
- W2062797692
- Cited by
- 2,877
- References
- 123
- Citations by year
- 2026: 53 · 2025: 55 · 2024: 84 · 2023: 95 · 2022: 110 · 2021: 139 · 2020: 104 · 2019: 148 · 2018: 130 · 2017: 137 · 2016: 136 · 2015: 151 · 2014: 150 · 2013: 152 · 2012: 151
- FWCI
- 14.92
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Milbank Quarterly (publishedVersion)
- PubMed (publishedVersion)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Healthcare Systems and Technology
- Keywords
- chronic care, care organization, primary care, managed care, integrated health system, evidence-based care, patient self-management, clinical data, provider role, care coordination
- MeSH terms
- Chronic Disease, Continuity of Patient Care, Humans, Patient Education as Topic, Primary Health Care, United States, Randomized Controlled Trials as Topic, Models, Organizational, Patient-Centered Care, Disease Management
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Statistics and arithmetic are recomputed, not judged.
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