The ACP's white paper cited several studies from the Institute of Medicine, Rand Corp., and CMS, indicating that care for chronically ill patients was fragmented and costly because of a lack of coordination under fee-for-service. This makes the large-scale testing of a patient-centered chronic care model “crucial to the health system's viability.”
Key elements of Dr. Wagner's model include:
▸ Mobilizing community resources to meet patient needs—for example, encouraging patients to participate in effective community programs.
▸ Reorganizing the health care system to encourage open and systematic handling of errors and quality problems to improve care and providing incentives to improve quality of care.
▸ Empowering and preparing patients to manage their health and health care, emphasizing the patient's central role in managing their health.
▸ Ensuring the delivery of effective clinical care and self-management support, such as providing clinical case management services for complex patients and giving care that patients understand and that fits with their cultural backgrounds.
▸ Promoting clinical care that's consistent with scientific evidence and patient preferences, embedding evidence-based guidelines into daily clinical practice.
▸ Organizing patient and population data to facilitate care, such as identifying subpopulations for proactive care, and sharing information with patients and providers to coordinate care.