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
Director, MacColl Center for Health Care Innovation
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

Cherkin DC, Anderson ML, Sherman KJ, Balderson BH, Cook AJ, Hansen KE, Turner JA. Two-year follow-up of a randomized clinical trial of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care for chronic low back pain. JAMA. 2017;317(6):642-644. doi: 10.1001/jama.2016.17814. PubMed

Green BB, Anderson ML, Chubak J, Baldwin LM, Tuzzio L, Catz S, Cole A, Vernon SW. Colorectal cancer screening rates increased after exposure to the Patient-Centered Medical Home (PCMH). J Am Board Fam Med. 2016;29(2):191-200. doi: 10.3122/jabfm.2016.02.150290. PubMed

Wagner EH. A first step on the journey to high-quality chronic illness care. Healthc Pap. 2016;15 Suppl:62-5. PubMed

Cherkin D, Balderson B, Brewer G, Cook A, Estlin KT, Evers SC, Foster NE, Hill JC, Hawkes R, Hsu C, Jensen M, LaPorte AM, Levine MD, Piekara D, Rock P, Sherman K, Sowden G, Wellman R, Yeoman J. Evaluation of a risk-stratification strategy to improve primary care for low back pain: the MATCH cluster randomized trial protocol. BMC Musculoskelet Disord. 2016 Aug 24;17(1):361. doi: 10.1186/s12891-016-1219-0. PubMed

Smith DH, Johnson ES, Boudreau DM, Cassidy-Bushrow AE, Fortmann SP, Greenlee RT, Gurwitz JH, Magid DJ, McNeal CJ, Reynolds K, Steinhubl SR, Thorp M, Tom JO, Vupputuri S, VanWormer JJ, Weinstein J, Yang X, Go AS, Sidney S. Comparative effectiveness of statin therapy in chronic kidney disease and acute myocardial infarction: a retrospective cohort study. Am J Med. 2015 Nov;128(11):1252.e1-1252.e11. doi: 10.1016/j.amjmed.2015.06.030. Epub 2015 Jul 11. PubMed

Researchers in Chronic Illness Management

Michael L. Parchman, MD, MPH

Director, MacColl Center for Health Care Innovation; Senior Investigator, GHRI
206-287-2704
parchman.m@ghc.org

Curriculum vitae (CV)

Edward H. Wagner, MD, MPH

Director (Emeritus), MacColl Center for Health Care Innovation
206-287-2877
wagner.e@ghc.org

Curriculum vitae (CV)

Michael R. Von Korff, ScD

Senior Investigator
206-287-2874
vonkorff.m@ghc.org

Curriculum vitae (CV)

Elizabeth H. Lin, MD, MPH

Adjunct Researcher, Kaiser Permanente Washington Health Research Institute; Physician, Washington Permanente Medical Group
206-287-4264
lin.e@ghc.org

Curriculum vitae (CV)

Katherine M. Newton, PhD

Senior Investigator (Emeritus)
206-287-2973
newton.k@ghc.org

Curriculum vitae (CV)

Beverly B. Green, MD, MPH

Associate Investigator
206-287-2997
green.b@ghc.org

Curriculum vitae (CV)

Katie Coleman, MSPH

Research Associate
206-287-2872
coleman.cf@ghc.org

Curriculum vitae (CV)

Judith Schaefer, MPH

Research Associate
206-287-2077
schaefer.jk@ghc.org

Curriculum vitae (CV)

Gregory E. Simon, MD, MPH

Senior Investigator
206-287-2979
simon.g@ghc.org

Curriculum vitae (CV)

Katharine A. Bradley, MD, MPH

Senior Investigator
206-287-2151
bradley.k@ghc.org

Curriculum vitae (CV)

Daniel C. Cherkin, PhD

Senior Investigator (Emeritus)
206-287-2875
cherkin.d@ghc.org

Curriculum vitae (CV)

Paul A. Fishman, PhD

Senior Investigator
206-287-2925
fishman.p@ghc.org

Curriculum vitae (CV)

Eric B. Larson, MD, MPH, MACP

Vice President for Research and Health Care Innovation, Kaiser Foundation Health Plan of Washington; Executive Director & Senior Investigator, Kaiser Permanente Washington Health Research Institute
206-287-2988
larson.e@ghc.org

Curriculum vitae (CV)

Paula Lozano, MD, MPH

Sr Investigator, Kaiser Permanente Washington Health Research Institute; Associate Medical Director for Research and Translation & Physician, Pediatrics, Washington Permanente Medical Group
206-884-8241
lozano.p@ghc.org

Curriculum vitae (CV)

Jennifer B. McClure, PhD

Director of Research, Faculty, & Development; Senior Investigator
206-287-2737
mcclure.j@ghc.org

Curriculum vitae (CV)

Karen J. Sherman, PhD

Senior Investigator
206-287-2426
sherman.k@ghc.org

Curriculum vitae (CV)

James D. Ralston, MD, MPH

Senior Investigator
206-287-2076
ralston.j@ghc.org

Curriculum vitae (CV)

Dori E. Rosenberg, PhD, MPH

Assistant Investigator
206-287-2532
rosenberg.d@ghc.org

Curriculum vitae (CV)

Evette J. Ludman, PhD

Senior Research Associate
206-287-2917
ludman.e@ghc.org

Curriculum vitae (CV)

Aruna Kamineni, MPH

Research Associate
206-287-2922
akaminen@fhcrc.org

Curriculum vitae (CV)

Ben Balderson, PhD

Research Associate
206-287-2803
balderson.b@ghc.org

Curriculum vitae (CV)

Andrea Hartzler, PhD

Assistant Investigator
206-287-2030
hartzler.a@ghc.org

Curriculum vitae (CV)

Nicole Van Borkulo, M Ed

Research Associate
206-287-2900
vanborkulo.n@ghc.org

Curriculum vitae (CV)

Leah Tuzzio, MPH

Research Associate
206-287-2109
tuzzio.l@ghc.org

Curriculum vitae (CV)

Predrag Klasnja, PhD

Associate Investigator
klasnja.p@ghc.org

Curriculum vitae (CV)

Joseph E. Glass, PhD

Assistant Scientific Investigator
206-287-4266
glass.j@ghc.org

Curriculum vitae (CV)

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