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Testing US-style chronic disease management

Dr Ben Sangowawa reports on a pilot scheme applying US methods of chronic disease care

Our inner-city practice with 25,000 patients has always been interested in improving the care of patients with chronic diseases. Two years ago we moved away from single-disease clinics and introduced chronic disease clinics with the aim of co-ordinating care more effectively – particularly for patients who suffered from more than one chronic disease.

Building on this approach, we offered to participate in a project that is trying to improve chronic disease management as part of Southwark PCT's service improvement programme. The project's aim is to improve the patient experience of chronic disease care across the whole pathway by implementing and testing a managed care approach.

Our PCT is one of six south London PCTs that have signed up to try out aspects of the Improving Chronic Illness Care (ICIC) model developed in the United States1,2. Where it has been implemented internationally, the model is reported to have achieved real improvements for patients, carers and staff. The project will test and adapt core components of the ICIC approach to chronic disease management, which include:

la focus on early, accurate diagnosis

lincreasing the ability of patients to master their disease and manage themselves

limproving patients' access to expert clinical support when they need it

lproactive management of patients' care during a hospital admission

lworking with patients on making choices about end-of-life care.

At our practice we are still in the early stages. A small design group of clinicians, managers and patients from our register with co-morbidities in CHD and diabetes has been meeting to agree which components of the ICIC model they would like to test in the coming year. Interventions likely to be tested are listed in the box above. The assumption is that a lot of chronic disease management will be generic across different conditions.

The project will be collecting monthly measures to track any changes in patients' experience, using data both on service utilisation – such as the number of primary care contacts, A&E attendance, length of stay – and patient perception (their ability to self-manage).

The most important thing for the practice is that in doing this work we try to see things through our patients' eyes and work with them to improve the care they experience.

Ben Sangowawa is a GP in Southwark,


Components of the model of care

lStratifying the patients by risk and offering them tailormade self-management programmes

lCo-ordinating their care through case managers

lTesting different ways for the patients to access specialist opinions

lUsing hand-held patient records

lWorking with community pharmacists to improve medicines management concordance


1 Wagner EH. Chronic disease care. BMJ 2004; 328:177-178

2 Wagner EH et al. Improving chronic illness care: translating evidence into action. Health Affairs 2001;20:64-78

Further information

Improving chronic illness care model:

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