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Alicia Romero is a 45-year-old woman from El Salvador who works as a nursing assistant at a nursing home. If she has an acute complaint such as back or knee pain, she will make an appointment to see her primary care nurse practitioner, but even then there is little time in the 15-minute visit to address her chronic medical ­issues such as diabetes, hypertension, and hyperlipidemia. The nurse practitioner has done her best to ­explain the importance of healthy eating, physical ­activity, and taking the five prescribed medications, but Senora Romero is busy with her job and caring for her sick mother and 8-year-old son and has not been able to take good care of herself. Her hemoglobin A1c (HbA1c) is 9.5, her blood pressure (BP) is usually 150 over 95 mm Hg, and her low-density lipoprotein (LDL) cholesterol is 140 mg/dL.

About 130 million people in the United States live with at least one chronic illness, a number expected to top 150 million by 2020. Over half of that population have multiple chronic conditions. People with chronic illnesses account for 80% of total health care expenditures. By 2023, 48 million people are expected to have diabetes and 47 million will have a chronic mental health ­problem. About one-half of the people with hypertension and two-thirds of those with diabetes are in poor control of their disease, demonstrating that even with proven treatments for most chronic conditions, the health care system is poorly organized to care for these conditions.

Chronic disease is a primary care problem. Of the visits for chronic illness, 83% for hyperlipidemia, 79% for hypertension, 72% for diabetes, 76% for asthma, and 71% for depression are visits to primary care practitioners rather than specialists. The rushed 15-minute visit, which on average needs to address three or more medical issues, is entirely inadequate to care for chronic conditions. Primary care practitioners are constrained by the “tyranny of the urgent,” the need to prioritize acute problems over chronic care management. As the case of Senora Romero reveals, the 15-minute visit constrains the nurse practitioner from helping her patient gain control of her three chronic conditions. To improve the care of chronic disease, primary care needs to be transformed, moving beyond the 15-minute visit and creating new ways to manage chronic illness. A vibrant movement within primary care has taken on this task, hoping to transform primary care practices into “patient-centered medical homes.”

Much of this chapter is devoted to a discussion of the Chronic Care Model (CCM), the guide to improving chronic care management. The end of the chapter describes the innovations taking place in primary care practices to implement the CCM.


The CCM (Figure 39-1) incorporates the community, health care system, health care team, and patients in a unified model designed to improve ...

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