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

Tisminetzky M, Bayliss EA, Magaziner JS, Allore HG, Anzuoni K, Boyd CM, Gill TM, Go AS, Greenspan SL, Hanson LR, Hornbrook MC, Kitzman DW, Larson EB, Naylor MD, Shirley BE, Tai-Seale M, Teri L, Tinetti ME, Whitson HE, Gurwitz J. Research priorities to advance the science of multiple chronic conditions in older adults. J Am Geriatrics Soc, doi: 10.1111/jgs.14943. [Epub ahead of print 2017, May 26].

Berry ABL, Lim C, Hartzler AL, Hirsch T, Ludman E, Wagner EH, Ralston JD. Eliciting values of patients with multiple chronic conditions: evaluation of a patient-centered framework. AMIA Annu Symp Proc. 2018 Apr 16;2017:430-439. eCollection 2017. PubMed

Elder CR, Debar LL, Ritenbaugh C, Rumptz MH, Patterson C, Bonifay A, Cowan P, Lancaster L, Deyo RA. Health care systems support to enhance patient-centered care: lessons from a primary care-based chronic pain management initiative. Perm J. 2017;21. doi: 10.7812/TPP/16-101. PubMed

Johnson ES, Dickerson JF, Vollmer WM, Rowley AM, Ritenbaugh C, Deyo RA, DeBar L. The feasibility of matching on a propensity score for acupuncture in a prospective cohort study of patients with chronic pain. BMC Med Res Methodol. 2017 Mar 16;17(1):42. doi: 10.1186/s12874-017-0318-4. PubMed

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

Researchers in Chronic Illness Management

Lynn DeBar, PhD

Senior Investigator
(206) 287-2942
Lynn.Debar@kp.org

Curriculum vitae (CV)

Michael L. Parchman, MD, MPH

Senior Investigator, MacColl Center for Health Care Innovation
206-287-2704
Michael.X.Parchman@kp.org

Curriculum vitae (CV)

Beverly B. Green, MD, MPH

Senior Investigator
206-287-2997
Bev.B.Green@kp.org

Curriculum vitae (CV)

James D. Ralston, MD, MPH

Senior Investigator
206-287-2076
James.D.Ralston@kp.org

Curriculum vitae (CV)

Predrag Klasnja, PhD

Associate Investigator, KPWHRI; Assistant Professor of Information, University of Michigan School of Information
206-442-5207
Predrag.V.Klasnja@kp.org

Curriculum vitae (CV)

Eric B. Larson, MD, MPH, MACP

Senior Investigator and former Executive Director, Kaiser Permanente Washington Health Research Institute; Former Vice President for Research and Health Care Innovation, Kaiser Permanente Washington
206-287-2988
Eric.B.Larson@kp.org

Curriculum vitae (CV)

Paula Lozano, MD, MPH

Senior Investigator, KPWHRI; Associate Medical Director for Research and Translation & Physician, Pediatrics, Washington Permanente Medical Group
206-287-2113
Paula.Lozano@kp.org

Curriculum vitae (CV)

Katie Coleman, MSPH

Director, Learning Health System Program
206-287-2872
Katie.F.Coleman@kp.org

Curriculum vitae (CV)

Gregory E. Simon, MD, MPH

Senior Investigator
206-287-2979
Gregory.E.Simon@kp.org

Curriculum vitae (CV)

Katharine A. Bradley, MD, MPH

Senior Investigator
206-287-2151
Katharine.A.Bradley@kp.org

Curriculum vitae (CV)

Jennifer B. McClure, PhD

Director of Research, Faculty, & Development; Senior Investigator
206-287-2737
Jennifer.B.Mcclure@kp.org

Curriculum vitae (CV)

Karen J. Sherman, PhD

Senior Investigator
206-287-2426
Karen.J.Sherman@kp.org

Dori E. Rosenberg, PhD, MPH

Associate Investigator
206-287-2532
Dori.E.Rosenberg@kp.org

Curriculum vitae (CV)

Aruna Kamineni, PhD, MPH

Assistant Investigator
206-287-2922
Aruna.S.Kamineni@kp.org

Curriculum vitae (CV)

Ben Balderson, PhD

Research Associate
206-287-2803
Benjamin.H.Balderson@kp.org

Curriculum vitae (CV)

Leah Tuzzio, MPH

Research Associate
206-287-2109
Leah.Tuzzio@kp.org

Curriculum vitae (CV)

Joseph E. Glass, PhD, MSW

Associate Investigator
206-287-4266
Joseph.E.Glass@kp.org

Curriculum vitae (CV)

Amy K. Lee, MPH

Research Associate
206-287-2827
Amy.K.Lee@kp.org

Curriculum vitae (CV)

Bridget Burke, PhD, MPH, MIS

Research Fellow
206-287-5252
Bridget.T.Burke@kp.org

Curriculum vitae (CV)

Katherine M. Newton, PhD

Senior Investigator (Emeritus)
206-287-2973
Katherine.M.Newton@kp.org

Curriculum vitae (CV)

Daniel C. Cherkin, PhD

Senior Investigator (Emeritus)
206-287-2875
Dan.C.Cherkin@kp.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