Chronic Illness Management

“We have moved from understanding what is required to deliver excellent care for individual patients with chronic illnesses to the immense challenge of learning how to implement what we know works at scale: the science of health care delivery.”

Michael Parchman, MD, MPH
Kaiser Permanente Washington Health Research Institute Senior Investigator

Research overview

What do diabetes, back pain, depression, and heart disease have in common? They're among a host of chronic health problems and disabilities that have traditionally received too little attention from health care systems — until serious complications develop. Modern medicine tends to focus on detecting and treating acute problems, leaving fewer resources for the needs of patients with chronic illnesses, which may be less urgent but are equally important.

Our population is aging rapidly, and people with chronic conditions are living longer. Chronic conditions now affect more than 145 million Americans. About half of Americans over 65 — our nation’s fastest-growing segment — have at least 2 chronic conditions. As our need for improved chronic care grows, health care delivery systems are trying to correct the many deficiencies in current management of chronic diseases.

“Much of our work now focuses on finding ways to give organizations the support and tools they need to build high-functioning health care teams that can engage patients, improving the quality and outcomes of their care,” says Michael Parchman, MD, MPH, senior investigator at Kaiser Permanente Washington Health Research Institute (KPWHRI) and a researcher within its Center for Accelerating Care Transformation (ACT Center).

"Meeting the complex needs of patients with chronic illness or impairment is the single greatest challenge facing organized medical practice," says Ed Wagner, MD, MPH, founder of the MacColl Center for Health Care Innovation, which joined with Kaiser Permanente Washington’s Learning Health System Program to form the ACT Center.

For over 2 decades, KPWHRI scientists have been developing, implementing, and promoting better models of care for chronic illness. Widely recognized for its refinement and dissemination of the Chronic Care Model, the ACT Center continues to work with providers nationwide to develop strategies and tools for health care systems seeking to improve chronic illness care.

Such resources are then shared globally through active engagement with international organizations developing guidance and care recommendations. Providers worldwide continue to adapt materials such as the ACT Center’s Patient Assessment of Chronic Illness Care and Patient-Centered Medical Home Assessment surveys.  

Recent publications on Chronic Illness Management

Gold LS, Cody RF, Tan K, Marcum ZA, Meier EN, Sherman KJ, James KT, Griffith B, Avins AL, Kallmes DF, Suri P, Friedly JL, Heagerty PJ, Deyo RA, Luetmer PH, Rundell SD, Haynor DR, Jarvik JG. Osteoporosis identification among previously undiagnosed individuals with vertebral fractures. OOsteoporos Int. 2022 Sep;33(9):1925-1935. doi: 10.1007/s00198-022-06450-7. Epub 2022 Jun 3. PubMed

Wagner EH. Organizing care for patients with chronic illness revisited. Milbank Q. 2019 Sep;97(3):659-664. doi: 10.1111/1468-0009.12416. Epub 2019 Aug 19. PubMed

Schuttner L, Parchman M. Team-based primary care for the multimorbid patient: matching complexity with complexity.  Am J Med. 2019 Apr;132(4):404-406. doi: 10.1016/j.amjmed.2018.09.029. Epub 2018 Oct 6. PubMed

Groeneweg M, Forrester S, Arnold B, Palazzo L, Zhu W, Yoon P, Scearce T. One-year outcomes of an integrated multiple sclerosis disease management program. J Manag Care Spec Pharm. 2018 May;24(5):458-463. doi: 10.18553/jmcp.2018.24.5.458. PubMed

Becker WC, DeBar LL, Heapy AA, Higgins D, Krein SL, Lisi A, Makris UE, Allen KD. A research agenda for advancing non-pharmacological management of chronic musculoskeletal pain: findings from a VHA state-of-the-art conference. J Gen Intern Med. 2018 May;33(Suppl 1):11-15. doi: 10.1007/s11606-018-4345-6. PubMed

Researchers in Chronic Illness Management

Lynn DeBar, PhD

Senior Investigator
(206) 287-2942
Lynn.Debar@kp.org

Curriculum vitae (CV)

Michael L. Parchman, MD, MPH

Senior Investigator, ACT Center
206-287-2704
Michael.X.Parchman@kp.org

Curriculum vitae (CV)

Beverly B. Green, MD, MPH

Senior Investigator
206-287-2997
Bev.B.Green@kp.org

Curriculum vitae (CV)

James D. Ralston, MD, MPH

Senior Investigator
206-287-2076
James.D.Ralston@kp.org

Curriculum vitae (CV)

Eric B. Larson, MD, MPH, MACP

Senior Investigator and former Executive Director, KPWHRI; Former Vice President for Research and Health Care Innovation, KPWA
206-287-2988
Eric.B.Larson@kp.org

Curriculum vitae (CV)

Paula Lozano, MD, MPH

Senior Investigator
206-287-2113
Paula.Lozano@kp.org

Curriculum vitae (CV)

Michael R. Von Korff, ScD

Senior Investigator (Emeritus)
206-287-2874
Michael.R.Vonkorff@kp.org

Curriculum vitae (CV)

Katie Coleman, MSPH

Director, Collaborative Science; Director, ACT Center
206-287-2872
Katie.F.Coleman@kp.org

Curriculum vitae (CV)

Gregory E. Simon, MD, MPH

Senior Investigator
206-287-2979
Gregory.E.Simon@kp.org

Curriculum vitae (CV)

Katharine A. Bradley, MD, MPH

Senior Investigator
206-287-2151
Katharine.A.Bradley@kp.org

Curriculum vitae (CV)

Jennifer B. McClure, PhD

Director, Investigative Science
206-287-2737
Jennifer.B.Mcclure@kp.org

Curriculum vitae (CV)

Karen J. Sherman, PhD

Senior Investigator
206-287-2426
Karen.J.Sherman@kp.org

Curriculum vitae (CV)

Dori E. Rosenberg, PhD, MPH

Associate Investigator
206-287-2532
Dori.E.Rosenberg@kp.org

Curriculum vitae (CV)

Aruna Kamineni, PhD, MPH

Assistant Investigator
206-287-2922
Aruna.S.Kamineni@kp.org

Curriculum vitae (CV)

Ben Balderson, PhD

Senior Collaborative Scientist
206-287-2803
Benjamin.H.Balderson@kp.org

Curriculum vitae (CV)

Joseph E. Glass, PhD, MSW

Associate Investigator
206-287-4266
Joseph.E.Glass@kp.org

Curriculum vitae (CV)

Yu-Ru Su, PhD

Assistant Biostatistics Investigator
206-287-2948
yuru.su@kp.org

Curriculum vitae (CV)

Chloe Krakauer, PhD

Collaborative Biostatistician II
chloe.a.krakauer@kp.org

Curriculum vitae (CV)

Mikael Anne Greenwood-Hickman, MPH

Collaborative Scientist
(206) 287-2908
Mikael.Anne.Greenwood-Hickman@kp.org

Laurel Hansell, MA, MPH

Collaborative Scientist
laurel.d.hansell@kp.org

Curriculum vitae (CV)

Claire Allen, MPH

Manager, Collaborative Science
Claire.L.Allen@kp.org

Curriculum vitae (CV)

Morgan Justice, MA

Collaborative Scientist
Morgan.J.Fuoco@kp.org

Curriculum vitae (CV)

Affiliate Researchers in Chronic Illness Management

Laura-Mae Baldwin, MD, MPH 
Professor, Department of Family Medicine
University of Washington

Linda LeResche, ScD
Associate Dean for Research, School of Dentistry
Professor, Oral Medicine
University of Washington