PI Pearl #1: Using the Wagner Chronic Care Model to Develop Performance Improvement Interventions

The Chronic Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and colleagues of the Improving Chronic Illness Care program with support from The Robert Wood Johnson Foundation.

There are six fundamental areas identified by the Chronic Care Model making up a system that encourages high-quality chronic disease management that involves patients in their care.

 
[Wagner EH. Chronic disease management: What will it take to improve care for 
chronic illness? Effective Clinical Practice. 1998;1(1):2-4.]

When developing PI CME, consider non-educational interventions for improving care that fit the Chronic Care Model.

Self Management—tools for patient home-monitoring
Decision Support—use of web-based clinical calculators
Delivery System Design—patient reminders, tickler systems for follow up appointments
Clinical Information System—use of registry to identify patients with specific diagnosis
Organization of Health Care—group visits for patient education and monitoring
Community—resource centers for patients listing community resources

These resources can be integrated into the CME activity to ensure physician learners have improvement tools to implement following the educational activity.