• Include a strong focus on patient information and self-management so patients and their families acquire skills in self-management and can make needed lifestyle changes. Structured self-management and behavioral change programs improve patient outcomes.

• Ensure the availability of specialized expertise to the primary care practices that frequently have responsibility for managing patients with chronic illness. The traditional mechanism for accessing expertise is through a consultation or referral, which runs the risk of fragmenting care. Alternative approaches for making expertise available include teams with specialized knowledge (e.g., a diabetologist and nurse specialist working with general practitioners who care for diabetic patients); collaborative care arrangements (e.g., where specialists and generalists manage patients together); and, eventually, well-designed computer decision support systems.

• Rely on having good information about patients, their care, and outcomes in order to improve outcomes. Registries inform providers which patients have certain conditions to permit proactive clinical management. Use of reminder systems supports patient participation in explicit plans of care.

Wagner (2000) also notes the implications of such a model for how teams of clinicians work together. Successful teams should bring in new disciplines in medicine, but also nonmedical personnel. Establishment of care plans, good patient involvement, and a strong information base permit members of a care team to work together beyond organizational and practice boundaries.

Although good coordination and communication are essential for all care, they are especially important for chronic care. Patients may move through many settings of care, from home, to clinician office, to hospital, to nursing home, and back. Patients and their families often provide a sizable proportion of routine care, including the administration of medications, performance of some diagnostic tests, and compliance with physical therapy and nutritional plans. While the current health care system is built around visits, people with chronic illness need flexible models that provide more time and alternative contacts with the system. Although there are many basic, simple techniques that can be employed today (e.g., telephone follow-up rather than e-mail, or reminder systems that use flags on a chart rather than computerized reminder systems), the committee believes these simple techniques have been available for many years and have not been sufficient to achieve broad-based quality improvements. While any type of progress is welcome, at some point the health care system will need to embrace more automated methods and greater use of information technology to make significant progress.

Unfortunately, there are very few well-tested integrated models of chronic care management (Wagner et al., 1996a). While research may focus on specific components of care, it is more difficult to understand the interrelationship between the components and the influence of the organizational environment. For