Implementing the Chronic Care Model: A Statewide Focus on Improving Diabetes Care for Pennsylvania

Chronic diseases represent a significant public health burden by decreasing quality of life and causing death and disability at great economic cost. In Pennsylvania, chronic diseases are the leading cause of death and disability and account for 80% of all health care costs. About half of all Pennsylvanians have a chronic disease, including diabetes, asthma, heart conditions, and others.¹ These chronic conditions are exacerbated by obesity, an older population, smoking, and other factors that are hardly unique to the state but statistically more prevalent. Unfortunately, reports also show that only 56% of patients in the state receive the kind of care recommended for chronic disease.^2.

The primary care system, through which most of chronic care is provided, is insufficiently oriented toward the management and maintenance of the chronically ill.³ Overburdened clinicians do not have ready access to information about their patients or time to meet all of their patients' needs. Furthermore, there is a lack of care coordination and follow-up, and patients often are inadequately trained to manage their disease.³ Primary care practices are also poorly compensated by insurers and government payers under existing reimbursement models. The potential consequences of poor management are grave, and much of the costs would be unnecessary if patients received evidence-based care in a setting in which multiple practitioners can communicate and collaborate.

The number of people with diabetes is expected to increase alarmingly in the coming decades. The International Diabetes Federation estimates that more than 250 million people around the world have diabetes. This total is expected to rise to 380 million within 20 years. Each year, an additional 7 million people develop diabetes.⁴ In the United States, the incidence of diabetes is also growing and nearly doubled between 1995 and 2006 to 7.4% of the population. …