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
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
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
Researchers in Chronic Illness Management
 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 |
 Predrag Klasnja, PhDAssistant Investigator, KPWHRI; Assistant Professor of Information, University of Michigan School of Information |
 Eric B. Larson, MD, MPH, MACPVice President for Research and Health Care Innovation, Kaiser Foundation Health Plan of Washington; Executive Director & Senior Investigator, KPWHRI |
 Paula Lozano, MD, MPHSenior Investigator, KPWHRI; Associate Medical Director for Research and Translation & Physician, Pediatrics, Washington Permanente Medical Group |
 Michael R. Von Korff, ScDSenior Investigator |
 Katie Coleman, MSPHDirector, 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, PhDAssistant Investigator |
 Ben Balderson, PhDResearch Associate |
 Leah Tuzzio, MPHResearch Associate |
 Joseph E. Glass, PhDAssistant Investigator |
 Amy K. Lee, MPHResearch Associate |
 Bridget Burke, PhD, MPH, MISResearch Fellow |
 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) |
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.
pain management
Six Building Blocks help small rural clinics to manage opioids better
Led by Dr. Michael Parchman, research team uses new way to support small clinics in reducing opioid use in rural Pacific Northwest.
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.
new frontiers
Do mast cells hold the key to chronic and unexplained disease?
Dr. Jennifer McClure reflects on evidence about mast cells as a key to chronic disease, providing new insights for physicians, researchers, and the public.
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.
