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The team excluded studies of "disease-management" interventions that worked with patients without engaging medical practices. In many such programs, Coleman said, commercial vendors encourage "high-cost" patients to manage their own chronic diseases betterwhile the medical practice stays the same. In the January 2009 Annual Review of Public Health, she concluded these interventions, also called "carve-outs," tend to be less effective than are those that use the Model. Not only helping people care for their own diseases, Model-based interventions also help medical practices make clinical changes to redesign how they deliver health care.

The Chronic Care Model comprises six interrelated system changes: effective team care; planned interactions; self-management support; community resources; integrated decision support; and patient registries and other supportive information technology (IT). Registries track patients with specific chronic diseases, helping medical teams to make the most of each office visit and follow evidence-based care guidelines. Electronic medical records, while useful, are not required. "There's no magic bullet, including IT," said Brian Austin, another review co-author, who is the associate director of Group Health's MacColl Institute. "No single element suffices alone."

Controlling chronic diseases better should save money. But the review concluded that realizing these savings may take longer than the studies, most of which ended within a year. And insurers, not healthcare providers, may get the savings. That is because most healthcare is reimbursed as fees for servicestests and treatmentsnot for patient support or disease control or prevention.

"We need to study whether the Model is cost-effectiveand find good ways to spread it to smaller practices," said Coleman. One promising option, with growing "buzz," is a reinvention of g
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