» Back to Table of Contents

Director's Letter

The Chronic Care Model is now close to 20 years old.¹ In it, Ed Wagner and his co-authors outlined six elements necessary to support an effective partnership between clinicians and patients to optimize care of chronic conditions: support for self-management skills of patients; clinical decision support based on evidence-based guidelines; electronic data infrastructure to track individual and population progress; a delivery system designed to promote collaboration; and supportive health systems and community resources where efforts and incentives are aligned. These elements have existed in VA for some time and should be further enhanced as dissemination of the Patient Aligned Care Team (PACT) model continues. It is thus no surprise that VA generally outperforms the private sector on many of the routine measures of chronic disease care, such as control of diabetes, high blood pressure and elevated lipids.² Doing well "on average" should not, however, distract us from the reality that performance is not uniformly good across our multiple facilities and diverse patient populations, and that we need new tools to improve care for those populations that still lag behind. Since Veterans spend the vast majority of their time outside the health system, the greatest opportunity for progress in VA (and outside VA) may be in improving the self-management skills of our patients. Most Veterans have more than one chronic condition and many have complex medical regimens with limited support at home. Traditional patient education (e.g., diabetes education clinics) is not sufficient for teaching sustainable self-management skills. As described in this issue, new approaches such as text messaging and peer support can extend the reach of clinicians and help create the type of patient engagement and activation needed for true self-management. The ongoing challenge will be to merge our efforts to promote collaborative, proactive care management with those to promote patient-centered care. The goal of care management cannot be to improve lab values and performance on quality metrics–optimal care must focus on those outcomes that really matter to the patient, which unfortunately are rarely captured in our traditional performance measures. That of course is a research agenda in itself.

David Atkins, MD, MPH, Acting Chief Research and Development Officer

1. Wagner EH, Austin BT, Von Korff M. "Organizing Care for Patients with Chronic Illness," Milbank Quarterly 1996; 74(4):511-44.
2. O'Hanlon C, Huang C, Sloss E, et al. "Comparing VA and Non-VA Quality of Care: A Systematic Review," Journal of General Internal Medicine 2016 Jul 15; Epub ahead of print.