Wagner model for managing chronic disease
E.H. Wagner argued that many chronically sick patients are not receiving adequate long-term care (Wagner EH. Managed care and chronic illness: health services research needs. Health Serv Res. 1997;32:702-14.). Conventional primary care is designed to handle acute conditions, so emphasizes brief clinical encounters to diagnose signs and symptoms, to arrange for triage, ensuring patient flow, and offering only brief patient education followed by patient-initiated follow-up care. This type of primary care needs to be redesigned to cope with long-term, incurable conditions.
Wagner's revision aimed to support patients in self-management of their condition by enhancing their own skills; this required engaging a broader team that includes links with community care agencies, tracking systems to monitor patient progress, and delegation of the central organizational role from physician to a case manager.
Source: Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Pract 1998;1:2-4.
Link: See also the Expanded chronic care model.