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 a researcher within 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 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.
Wagner EH. Organizing care for patients with chronic illness revisited. Milbank Q. 2019 Sep;97(3):659-664. doi: 10.1111/1468-0009.12416. Epub 2019 Aug 19. PubMed
Schuttner L, Parchman M. Team-based primary care for the multimorbid patient: matching complexity with complexity. Am J Med. 2019 Apr;132(4):404-406. doi: 10.1016/j.amjmed.2018.09.029. Epub 2018 Oct 6. 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 May;33(Suppl 1):11-15. doi: 10.1007/s11606-018-4345-6. PubMed
![]() Lynn DeBar, PhDSenior Investigator |
![]() Michael L. Parchman, MD, MPHSenior Investigator, MacColl Center for Health Care Innovation |
![]() Beverly B. Green, MD, MPHSenior Investigator |
![]() James D. Ralston, MD, MPHSenior Investigator |
![]() Eric B. Larson, MD, MPH, MACPSenior Investigator and former Executive Director, Kaiser Permanente Washington Health Research Institute; Former Vice President for Research and Health Care Innovation, Kaiser Permanente Washington |
![]() Paula Lozano, MD, MPHSenior Investigator, Kaiser Permanente Washington Health Research Institute; |
![]() Michael R. Von Korff, ScDSenior Investigator (Emeritus) |
![]() Katie Coleman, MSPHDirector, MacColl Center for Health Care Innovation; Director, Learning Health System Program |
![]() 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, PhD, MPHAssistant Investigator |
![]() Ben Balderson, PhDResearch Associate |
![]() Leah Tuzzio, MPHSenior Research Associate |
![]() Joseph E. Glass, PhD, MSWAssociate Investigator |
![]() Amy K. Lee, MPHResearch Associate |
![]() Edward H. Wagner, MD, MPHDirector (Emeritus, Retired), MacColl Center for Health Care Innovation |
![]() Katherine M. Newton, PhDSenior Investigator (Emeritus) |
![]() Daniel C. Cherkin, PhDSenior Investigator (Emeritus) |
![]() Yu-Ru Su, PhDAssistant Investigator |
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