Edward Wagner: The chronic care model and integrated care

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  • Posted:Monday 04 November 2013

Chris Ham talks to Edward Wagner, Director Emeritus, MacColl Center for Health Care Innovation, Group Health Research Institute, about co-ordinated care and the chronic care model.


Dr Wagner explains how his clinical work helped him to develop the chronic care model, encouraging the medical workforce to collaborate with patients to help them to manage and choose their own care.

He discusses who needs to be in a successful care team, how important a named caregiver is, and how the co-ordinated care model can be used to deliver more appropriate care for older people.


Nicola Kingston

Citizens Board SLIC,
Healthwatch Lambeth
Comment date
04 November 2013
Need to ensure commissioning team includes patient and Carers as leaders.
Need to be skilled up to play equal commissioning, service redesign role.

Neil @nchadborn

Research fellow,
University of Nottingham
Comment date
05 November 2013
Great interview -so many important points:
Health literacy should be gained in collaboration with patient, not didactic instructions.
Proactive Prepared Team should include GP, but probably not as leader, someone to support self-care, someone to support logistics eg transport.
Hunt's 'accountable clinician' should be a generalist with whole-person knowledge of patient who coordinates care - by previous comment, this precludes GP!
Integration relates to organisations - prioritise coordinated care: the deliberate activity of a team to protect patient from pitfalls of having to get care from different organisations

Yun-Hee Jeon

Associate Professor,
The University of Sydney
Comment date
21 November 2013
It's so great to be reminded about the importance of patient/person centred care - especially the notion of 'knowing the person', how the system and health professionals should respond to be actually 'patient/person centred'. For someone who has spent more than a decade on developing and promoting evidence for person centred dementia care, and been continually disappointed by slowness of this philosophy embedded in our health care and service delivery, I am quite encouraged to hear this interview.

abayomi Erinoso

Student Nurse,
Middlesex University
Comment date
10 December 2020

I am happy to hear about the importance of collaborative working. Also, giving a service users a central role to play in their treatments, with empathy and non judgmental attitudes.

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