Building Health Systems for People with Chronic Illnesses was a national initiative, funded by The Robert Wood Johnson Foundation from 1993 to 2002, aimed at improving the delivery of biomedical, mental health, and social support services for people with disabilities and chronic conditions requiring long-term care.¹⁹ A qualitative analysis of the five programs most successful in integrating the delivery of all three types of care identified the following as key elements in achieving such outcomes as improved health, reduced use of the emergency room and hospital inpatient and residential mental health care, and reduced or contained costs: (1) screening, needs assessment, and care planning; (2) consumer participation, decision support, and self-determination in care planning; and (3) mechanisms for linking biomedical and psychosocial health services, such as use of interdisciplinary teams and case management (Palmer and Somers, 2005).

The Chronic Care Model is intended to improve the health outcomes of people with chronic illness by creating informed, activated patients who can interact effectively with prepared, proactive health care teams (Bodenheimer et al., 2002). To this end, the model prescribes six key actions for health care organizations serving individuals with chronic illness: (1) supporting patients in learning about and managing their illnesses (illness self-management); (2) helping patients use community resources to manage their health; (3) redesigning patient care by, for example, redefining roles of care team members, offering case management services for complex cases, and providing regular follow-up of all patients; (4) using clinical information systems to support individual patient care planning and coordination of care and to otherwise facilitate efficient and effective care;