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About 125 million of the 276 million people living in the United States have some type of chronic illness (table 1). 1 Four chronic conditions affect nearly half of Americans with a chronic disease: asthma, depression, and diabetes each affect about 15 million, 2–4 while five million have congestive heart failure. 5 In 1999 these four chronic diseases were directly responsible for 140 000 deaths in the United States6 and generated at least $173 bn (£ 108bn,€ 170bn) in medical and other costs. 5 7–9

Over the past decade the effectiveness of care for patients with these and other major chronic illnesses has been improved by innovations in care management processes such as the use of guidelines, disease management techniques, case management, and patient education to improve self management of chronic disease. 10 However, many patients are not benefiting from these advances. Recent studies indicate that …