Chronic Illness Management
“We have moved from understanding what is required to deliver excellent care for individual patients with chronic illnesses to the immense challenge of learning how to implement what we know works at scale: the science of health care delivery.”
Michael Parchman, MD, MPH
Kaiser Permanente Washington Health Research Institute Senior Investigator
Research overview
What do diabetes, back pain, depression, and heart disease have in common? They're among a host of chronic health problems and disabilities that have traditionally received too little attention from health care systems—until serious complications develop. Modern medicine tends to focus on detecting and treating acute problems, leaving fewer resources for the needs of chronically ill patients, which may be less urgent but are equally important.
Our population is aging rapidly, and people with chronic conditions are living longer. Chronic conditions now affect more than 145 million Americans. About half of Americans over 65—our nation’s fastest-growing segment—have at least two chronic conditions. As our need for improved chronic care grows, health care delivery systems are trying to correct the many deficiencies in current management of chronic diseases.
“Much of our work now focuses on finding ways to give organizations the support and tools they need to build high-functioning health care teams that can engage patients, improving the quality and outcomes of their care,” says Michael Parchman, MD, MPH, senior investigator at Kaiser Permanente Washington Health Research Institute (KPWHRI) and director of its MacColl Center for Health Care Innovation.
"Meeting the complex needs of patients with chronic illness or impairment is the single greatest challenge facing organized medical practice," says Ed Wagner, MD, MPH, senior investigator and founder and director (emeritus) of KPWHRI’s MacColl Center.
For nearly two decades, KPWHRI scientists have been developing, implementing, and promoting better models of care for chronic illness. Widely recognized for its refinement and dissemination of the Chronic Care Model (CCM), the Institute’s MacColl Center continues to work with providers nationwide to develop strategies and tools for health care systems seeking to improve chronic illness care.
Such resources are then shared globally through active engagement with international organizations developing guidance and care recommendations. Providers worldwide continue to adapt materials such as MacColl’s Patient Assessment of Chronic Illness Care (PACIC) and Patient-Centered Medical Home Assessment (PCMH-A) surveys.
Recent publications on Chronic Illness Management
Schuttner L, Parchman M. Team-based primary care for the multimorbid patient: matching complexity with complexity. Am J Med. 2018 Oct 6. pii: S0002-9343(18)30953-7. doi: 10.1016/j.amjmed.2018.09.029. [Epub ahead of print]. PubMed
Groeneweg M, Forrester S, Arnold B, Palazzo L, Zhu W, Yoon P, Scearce T. One-year outcomes of an integrated multiple sclerosis disease management program. J Manag Care Spec Pharm. 2018 May;24(5):458-463. doi: 10.18553/jmcp.2018.24.5.458. PubMed
Kligler B, Bair MJ, Banerjea R, DeBar L, Ezeji-Okoye S, Lisi A, Murphy JL, Sandbrink F, Cherkin DC. Clinical policy recommendations from the VHA state-of-the-art conference on non-pharmacological approaches to chronic musculoskeletal pain. J Gen Intern Med. 2018 Apr 9. pii: 10.1007/s11606-018-4323-z. doi: 10.1007/s11606-018-4323-z. [Epub ahead of print]. PubMed
Becker WC, DeBar LL, Heapy AA, Higgins D, Krein SL, Lisi A, Makris UE, Allen KD. A research agenda for advancing non-pharmacological management of chronic musculoskeletal pain: findings from a VHA state-of-the-art conference. J Gen Intern Med. 2018 Apr 9. pii: 10.1007/s11606-018-4345-6. doi: 10.1007/s11606-018-4345-6. [Epub ahead of print]. PubMed
Suri P, Delaney K, Rundell SD, Cherkin DC. Predictive validity of the STarTback tool for risk of persistent disabling back pain in a United States primary care setting. Arch Phys Med Rehabil. 2018 Apr 3. pii: S0003-9993(18)30204-1. doi: 10.1016/j.apmr.2018.02.016. [Epub ahead of print]. PubMed
Researchers in Chronic Illness Management
 Lynn DeBar, PhDSenior Investigator |
 Michael L. Parchman, MD, MPHSenior Investigator, MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute |
 Beverly B. Green, MD, MPHSenior Investigator |
 James D. Ralston, MD, MPHSenior Investigator |
 Predrag Klasnja, PhDAssistant Investigator |
 Eric B. Larson, MD, MPH, MACPVice President for Research and Health Care Innovation, Kaiser Foundation Health Plan of Washington; Executive Director & Senior Investigator, Kaiser Permanente Washington Health Research Institute |
 Paula Lozano, MD, MPHSr Investigator, Kaiser Permanente Washington Health Research Institute; Associate Medical Director for Research and Translation & Physician, Pediatrics, Washington Permanente Medical Group |
 Michael R. Von Korff, ScDSenior Investigator |
 Elizabeth H. Lin, MD, MPHAdjunct Researcher, Kaiser Permanente Washington Health Research Institute; Physician, Washington Permanente Medical Group |
 Katie Coleman, MSPHDirector, Learning Health System Program |
 Judith Schaefer, MPHResearch Associate |
 Gregory E. Simon, MD, MPHSenior Investigator |
 Katharine A. Bradley, MD, MPHSenior Investigator |
 Jennifer B. McClure, PhDDirector of Research, Faculty, & Development; Senior Investigator |
 Karen J. Sherman, PhDSenior Investigator |
 Dori E. Rosenberg, PhD, MPHAssociate Investigator |
 Aruna Kamineni, PhDAssistant Investigator |
 Ben Balderson, PhDResearch Associate |
 Leah Tuzzio, MPHResearch Associate |
 Joseph E. Glass, PhDAssistant Scientific Investigator |
 Amy K. Lee, MPHResearch Associate |
 Bridget Burke, PhD, MPH, MISResearch Fellow |
 Edward H. Wagner, MD, MPHDirector (Emeritus), MacColl Center for Health Care Innovation |
 Katherine M. Newton, PhDSenior Investigator (Emeritus) |
 Daniel C. Cherkin, PhDSenior Investigator (Emeritus) |
Affiliate Researchers in Chronic Illness Management
Laura-Mae Baldwin, MD, MPH
Professor, Department of Family Medicine
University of Washington
Linda LeResche, ScD
Associate Dean for Research, School of Dentistry
Professor, Oral Medicine
University of Washington
opioid research
Opioids may raise risks for serious infections
In Annals editorial Drs. Sascha Dublin and Michael Von Korff advocate more caution in prescribing these medications
Read it in Healthy Findings.
Taking Action on Overuse
In health care, more isn’t always better. We know what to do less of, but how?
Our ‘Taking Action on Overuse’ framework helps organizations build a culture where care teams take ownership for reducing low value care. But what does that look like?
Read it in Healthy Findings.
Recent News
Patients may not be telling their doctors what matters to them most
KPWHRI’s VITAL study discovers six domains that people with chronic illness too rarely discuss with their care providers.
Read about it & watch the video in News and Events.
KPWHRI In the Media
Group Health’s guidelines helped our Group Practice reduce doses of opioids for chronic pain
Tackling chronic pain while reducing opioid use
Patient-Centered Outcomes Research Institute, May 11, 2017
KPWHRI In the Media
Mindfulness meditation eases chronic low back pain
Computerized phone therapy might help curb back pain
Reuters, Apr. 3, 2017
KPWHRI In the Media
Chronic illness management
Study aims to reduce painkiller abuse via primary care
Yakima Herald, March 9, 2017
opioid epidemic
Macklemore, John Oliver join opioid epidemic awareness fight
As pop culture icons address the dangers of prescription opioid abuse, Dr. Michael Von Korff sees hope for raising the issue in public consciousness.
Read it in Healthy Findings.
