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 patients with chronic illnesses, 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 2 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 Center for Accelerating Care Transformation (ACT Center).
"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, founder of the MacColl Center for Health Care Innovation, which joined with Kaiser Permanente Washington’s Learning Health System Program to form the ACT Center.
For over 2 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, the ACT 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 the ACT Center’s Patient Assessment of Chronic Illness Care and Patient-Centered Medical Home Assessment surveys.
Recent publications on Chronic Illness Management
Wessel J, Chu AY, Willems SM, Wang S, Yaghootkar H, Brody JA, Dauriz M, Hivert MF, Raghavan S, Lipovich L, Hidalgo B, Fox K, Huffman JE, An P, Lu Y, Rasmussen-Torvik LJ, Grarup N, Ehm MG, Li L, Baldridge AS, Stancáková A, Abrol R, Besse C, Boland A, Bork-Jensen J, Fornage M, Freitag DF, Garcia ME, Guo X, Hara K, Isaacs A, Jakobsdottir J, Lange LA, Layton JC, Li M, Hua Zhao J, Meidtner K, Morrison AC, Nalls MA, Peters MJ, Sabater-Lleal M, Schurmann C, Silveira A, Smith AV, Southam L, Stoiber MH, Strawbridge RJ, Taylor KD, Varga TV, Allin KH, Amin N, Aponte JL, Aung T, Barbieri C, Bihlmeyer NA, Boehnke M, Bombieri C, Bowden DW, Burns SM, Chen Y, Chen YD, Cheng CY, Correa A, Czajkowski J, Dehghan A, Ehret GB, Eiriksdottir G, Escher SA, Farmaki AE, Frånberg M, Gambaro G, Giulianini F, Goddard WA, Goel A, Gottesman O, Grove ML, Gustafsson S, Hai Y, Hallmans G, Heo J, Hoffmann P, Ikram MK, Jensen RA, Jørgensen ME, Jørgensen T, Karaleftheri M, Khor CC, Kirkpatrick A, Kraja AT, Kuusisto J, Lange EM, Lee IT, Lee WJ, Leong A, Liao J, Liu C, Liu Y, Lindgren CM, Linneberg A, Malerba G, Mamakou V, Marouli E, Maruthur NM, Matchan A, McKean-Cowdin R, McLeod O, Metcalf GA, Mohlke KL, Muzny DM, Ntalla I, Palmer ND, Pasko D, Peter A, Rayner NW, Renström F, Rice K, Sala CF, Sennblad B, Serafetinidis I, Smith JA, Soranzo N, Speliotes EK, Stahl EA, Stirrups K, Tentolouris N, Thanopoulou A, Torres M, Traglia M, Tsafantakis E, Javad S, Yanek LR, Zengini E, Becker DM, Bis JC, Brown JB, Adrienne Cupples L, Hansen T, Ingelsson E, Karter AJ, Lorenzo C, Mathias RA, Norris JM, Peloso GM, Sheu WH, Toniolo D, Vaidya D, Varma R, Wagenknecht LE, Boeing H, Bottinger EP, Dedoussis G, Deloukas P, Ferrannini E, Franco OH, Franks PW, Gibbs RA, Gudnason V, Hamsten A, Harris TB, Hattersley AT, Hayward C, Hofman A, Jansson JH, Langenberg C, Launer LJ, Levy D, Oostra BA, O'Donnell CJ, O'Rahilly S, Padmanabhan S, Pankow JS, Polasek O, Province MA, Rich SS, Ridker PM, Rudan I, Schulze MB, Smith BH, Uitterlinden AG, Walker M, Watkins H, Wong TY, Zeggini E; EPIC-InterAct Consortium, Laakso M, Borecki IB, Chasman DI, Pedersen O, Psaty BM, Shyong Tai E, van Duijn CM, Wareham NJ, Waterworth DM, Boerwinkle E, Linda Kao WH, Florez JC, Loos RJ, Wilson JG, Frayling TM, Siscovick DS, Dupuis J, Rotter JI, Meigs JB, Scott RA, Goodarzi MO; EPIC-InterAct Consortium. Low-frequency and rare exome chip variants associate with fasting glucose and type 2 diabetes susceptibility. Nat Commun. 2015 Jan 29;6:5897. doi: 10.1038/ncomms6897. PubMed
Nichols GA, Schroeder EB, Karter AJ, Gregg EW, Desai J, Lawrence JM, O'Connor PJ, Xu S, Newton KM, Raebel MA, Pathak RD, Waitzfelder B, Segal J, Lafata JE, Butler MG, Kirchner HL, Thomas A, Steiner JF. Trends in diabetes incidence among 7 million insured adults, 2006-2011: the SUPREME-DM project. Am J Epidemiol. 2015 Jan 1;181(1):32-9. doi: 10.1093/aje/kwu255. Epub 2014 Dec 16. PubMed
Jones SM, Amtmann D. The relationship of age, function, and psychological distress in multiple sclerosis. Psychol Health Med. 2015;20(6):629-34. doi: 10.1080/13548506.2014.979209. Epub 2014 Nov 4. PubMed
O'Connor PJ, Schmittdiel JA, Pathak RD, Harris RI, Newton KM, Ohnsorg KA, Heisler M, Sterrett AT, Xu S, Dyer WT, Raebel MA, Thomas A, Schroeder EB, Desai JR, Steiner JF. Randomized trial of telephone outreach to improve medication adherence and metabolic control in adults with diabetes. Diabetes Care. 2014 Dec;37(12):3317-24. doi: 10.2337/dc14-0596. Epub 2014 Oct 14. PubMed
Lundin JI, Ton TG, LaCroix AZ, Longstreth WT, Franklin GM, Swanson PD, Smith-Weller T, Racette BA, Checkoway H. Formulations of hormone therapy and risk of Parkinson's disease. Mov Disord. 2014 Nov;29(13):1631-6. doi: 10.1002/mds.26037. Epub 2014 Sep 25. PubMed
Researchers in Chronic Illness Management
 Beverly B. Green, MD, MPHSenior Investigator |
 James D. Ralston, MD, MPHSenior Investigator |
 Paula Lozano, MD, MPHSenior Investigator; Director, ACT Center |
 Katie Coleman, MSPHDirector, Collaborative Science; Director, ACT Center |
 Gregory E. Simon, MD, MPHSenior Investigator |
 Katharine A. Bradley, MD, MPHSenior Investigator |
 Jennifer B. McClure, PhDDirector, Investigative Science |
 Dori E. Rosenberg, PhD, MPHAssociate Investigator |
 Ben Balderson, PhDSenior Collaborative Scientist |
 Joseph E. Glass, PhD, MSWAssociate Investigator |
 Yu-Ru Su, PhDAssistant Biostatistics Investigator |
 Chloe Krakauer, PhDCollaborative Biostatistician |
 Mikael Anne Greenwood-Hickman, MPHCollaborative Scientist |
 Laurel Hansell, MA, MPHCollaborative Scientist |
 Claire Allen, MPHManager, Collaborative Science |
 Morgan Justice, MACollaborative Scientist |
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
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