Thank you for visiting Improving Chronic Illness Care!

Our funding for updating this website ended in 2011, but the resources we developed are still helping clinical practices from around the world to transform the care they provide to better serve patients with chronic illness. Please visit our home page to learn more—or check out our more recent tools and resources at:

















What is a chronic condition?
There are many definitions of "chronic condition," some more expansive than others. We characterize it as any condition that requires ongoing adjustments by the affected person and interactions with the health care system.

The prevalence is rising
2005 data showed that more than 133 million people, or almost half of all Americans, live with a chronic condition. 1 That number is projected to increase by more than one percent per year by 2030, resulting in an estimated population of 171 million requiring chronic disease management.

Management of multiple chronic conditions requires a transformation in health care
Almost half of all people with chronic illness have multiple conditions. As a result, many managed care and integrated delivery systems have taken a great interest in correcting the many deficiencies in current management of diseases such as diabetes, heart disease, depression, asthma and others. 2, 3, 4

Those deficiencies include:

  • Rushed practitioners not following established practice guidelines
  • Lack of care coordination and planned care
  • Lack of active follow-up to ensure the best outcomes
  • Patients inadequately trained to manage their illnesses

Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible. 5, 6, 7 To speed the transition, in 1998, Improving Chronic Illness Care created the Chronic Care Model, which summarizes the basic elements for improving care in health systems at the community, organization, practice and patient levels. Evidence on the effectiveness of the Chronic Care Model was summarized in 2009. 16

Primary care practices play an important role in frontline management of chronic disease
The MacColl Center for Health Care Innovation built an online resource that gives practices access to the same tools and approaches used by 31 of the most effective, team-based primary care practices in the United States. The Primary Care Team Guide 17 presents practical advice, case studies, and numerous resources that help practices become high-functioning teams and markedly improve care. Assessments identify where practices need to focus. Ensuring access to high quality, team-based care is one of the most effective interventions for improving the health of people with chronic illness.