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

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

Swerdlow DI, Preiss D, Kuchenbaecker KB, Holmes MV, Engmann JE, Shah T, Sofat R, Stender S, Johnson PC, Scott RA, Leusink M, Verweij N, Sharp SJ, Guo Y, Giambartolomei C, Chung C, Peasey A, Amuzu A, Li K, Palmen J, Howard P, Cooper JA, Drenos F, Li YR, Lowe G, Gallacher J, Stewart MC, Tzoulaki I, Buxbaum SG, van der A DL, Forouhi NG, Onland-Moret NC, van der Schouw YT, Schnabel RB, Hubacek JA, Kubinova R, Baceviciene M, Tamosiunas A, Pajak A, Topor-Madry R, Stepaniak U, Malyutina S, Baldassarre D, Sennblad B, Tremoli E, de Faire U, Veglia F, Ford I, Jukema JW, Westendorp RG, de Borst GJ, de Jong PA, Algra A, Spiering W, der Zee AH, Klungel OH, de Boer A, Doevendans PA, Eaton CB, Robinson JG, Duggan D; DIAGRAM Consortium, MAGIC Consortium, InterAct Consortium, Kjekshus J, Downs JR, Gotto AM, Keech AC, Marchioli R, Tognoni G, Sever PS, Poulter NR, Waters DD, Pedersen TR, Amarenco P, Nakamura H, McMurray JJ, Lewsey JD, Chasman DI, Ridker PM, Maggioni AP, Tavazzi L, Ray KK, Seshasai SR, Manson JE, Price JF, Whincup PH, Morris RW, Lawlor DA, Smith GD, Ben-Shlomo Y, Schreiner PJ, Fornage M, Siscovick DS, Cushman M, Kumari M, Wareham NJ, Verschuren WM, Redline S, Patel SR, Whittaker JC, Hamsten A, Delaney JA, Dale C, Gaunt TR, Wong A, Kuh D, Hardy R, Kathiresan S, Castillo BA, van der Harst P, Brunner EJ, Tybjaerg-Hansen A, Marmot MG, Krauss RM, Tsai M, Coresh J, Hoogeveen RC, Psaty BM, Lange LA, Hakonarson H, Dudbridge F, Humphries SE, Talmud PJ, Kivimäki M, Timpson NJ, Langenberg C, Asselbergs FW, Voevoda M, Bobak M, Pikhart H, Wilson JG, Reiner AP, Keating BJ, Hingorani AD, Sattar N. HMG-coenzyme A reductase inhibition, type 2 diabetes, and bodyweight: evidence from genetic analysis and randomised trials. Lancet. 2015 Jan 24;385(9965):351-61. doi: 10.1016/S0140-6736(14)61183-1. Epub 2014 Sep 24. 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, MacColl Center for Health Care Innovation; 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

Curriculum vitae (CV)

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)

Edward H. Wagner, MD, MPH

Director (Emeritus, Retired), MacColl Center for Health Care Innovation
206-287-2877
Brian.T.Austin@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)

Yu-Ru Su, PhD

Biostatistician
206-287-2948
yuru.su@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