James M. Anderson Center for Health Systems Excellence

  • A Roadmap for Teams Treating Patients with Chronic Conditions

    Our condition-based efforts are rooted in Wagner and colleagues' Chronic Care Model, developed to guide disease-based teams in improving outcomes.  The model describes the key elements of system change necessary to improve outcomes. 

    As we progressed in our work, we learned that within the pediatric specialty context, there was a sequencing to the elements that was particularly effective. We also believed that the incorporation of research at critical stages would allow us to push beyond the limits of current knowledge and set new boundaries for what could be achieved. 

    The result was a roadmap that our teams follow in undertaking their work. It leads them through the formation of their teams, development of measures and standardization of evidence-based care.  Later elements include the system work of care coordination, self-management support and shared decision making by families and care providers. The final step is hardwiring the changes into everyday practice and job responsibilities. 

    Our current focus is on accelerating the pace at which new disease-based teams initiate work and on developing prototypes where there are no proven models (such as care coordination and IT-enabled population management systems).  

    At Cincinnati Children’s, we believe that there is no limit to what we can accomplish as we push the boundaries of practice and knowledge to achieve the best possible outcomes for our patients.