Individualized stepped care of chronic illness.

The routine care of people with chronic illnesses often fails to follow evidence-based guidelines or to achieve optimal outcomes.1,2 Because of the high prevalence and costs of chronic illness care3,4 and the key role of primary care physicians in managing chronic illness, enhancing care and outcomes in primary care settings is a public health imperative. There are important general issues about how chronic conditions are effectively managed.1,5,6 Identifying these generalities is essential if the potential advantages of primary care of chronic illness are to be realized. Evidence-based guidelines for diverse chronic conditions identify similar elements of patient care (first table,second table).7,8,9,10,11,12 These elements include a well-defined care plan, patient education, scheduled follow ups, outcome and adherence monitoring, the targeted use of specialist consultation or referral, and the use of stepwise treatment protocols. Despite evidence that these elements of chronic illness care improve patient outcomes, they are often inadequately organized and delivered.1 Table 1 Generic elements of chronic illness care included in evidence-based guidelines for 5 chronic conditions Table 2 Individualized stepped care: a scheme for managing chronic illness in primary care