Chronic Models: the Wagnerian keys

Chris Ham, King's Fund Director, interviews Edward Wagner, Director Emeritus of MacColl Center for Healthcare Innovation Group Health Research Institute and promoter of the chronic patients care model (Chronic Care Model or CCM). As I think it is worth it, I decided to share a transcript summary of the conversation. It will not disappoint you.

Ham: How did you come up with the idea for CCM?

Wagner: From my own clinical practice. For me it was frustrating to see how well prepared and well-meaning physicians, when they had to deal with caring for chronic patients, failed to achieve good results, while we were starting to have evidence that by doing things differently, patients could better understand what was happening to them and could improve clinical outcomes. And for this reason I thought we had to share this evidence with the doctors.


Ham: What is the role of the patient in CCM?

Wagner: In medicine we learned that the patients did not have any role in the clinical decision making. It was assumed that they had to do what they were told. And as much as we wanted to believe that being didactic towards the patients, the solution is quite different. CCM calls that the doctor and the patient together to develop a care plan, in accordance with the values ​​and each individual patient.

Ham: CCM was speaking of team medicine, what team?

Wagner: It’s a team where only care plan relevant professionals are in it. But in relation to this question, the most important aspect of CCM is that both the team and the patient must share all the information in the care plan.

Ham: What is the role of the general practitioner in CCM?

Wagner: The primary care physician is a key member of the team, but not necessarily the leader. For the proper conduct of each care plan, clinical skills are necessary but not sufficient. They need professionals to help in making things work as planned, and I mean social issues, logistics, access to visitors, understanding, etc. And by this, I mean it’s often not efficient for the team leader to be the family doctor.

Ham: Let's talk about complex chronic patients.

Wagner: When dealing with patients with multimorbidity and complex needs, the problems multiply but above all, the social and coordination needs. Teams must be very skilled in order to adapt to the new requirements which stresses the ways in which the CCM professionals collaborate with the specialists and their ability to implement the necessary services in an effective manner.

Ham: The integration of care services is therefore the answer.

Wagner: I prefer coordination of services. We must ensure that all team members’ work in the direction agreed by the care plan and also their ability to protect the patient from the pitfalls that wait behind every corner of the system. If integration promotes coordination, then yes integration is the answer.

Ham: Is the recipe for the frail elderly patients similar?

Wagner: Absolutely. Each person requiring various services more or less continuously should have a professional with a general perspective, not necessarily the doctor. We’re talking about a professional who has to have a general vision of the care plan, but above all, and most importantly, who knows the patients well: how they live, what they think, etc. And in this respect, we must admit that not even the best integrated systems have succeeded yet.

Ham: What should be the role of the specialists?

Wagner:  Specialists can help, but the care plan is the key instrument. What we are sure of is that chronic patients and frail older people cannot be left alone in the hands of specialists.

Ham: And to finish?

Wagner: The transition from the current model should be made in small steps. The key is to approach patient by patient. General policies through agencies and major recommendations aren’t working.

Wagner's recommendation to address chronic patients: generate effective coordination, step by step, one patient at a time. Elaborate an individualized care plan for each patient and forget regulations and general recommendations.


Jordi Varela

Editor