Chronic care perspectives

Introduction

Chronic conditions are the leading causes of illness, disability, and death in the United States today. In 2014, 60% of U. S. adults had at least one chronic disease, and 42% had more than one chronic condition. Diabetes alone affects more than 29 million people in the United States. Recent evidence suggests that the prevalence of chronic diseases and their mortality and morbidity rates have increased in the past 5 years. This increase is particularly significant among adults aged 65 and older. Almost 50 million Americans are disabled by a chronic condition. By 2030, this number is expected to grow to 171 million people. In addition to the personal burden of disease, the costs to the U.S. health care system are staggering. National health expenditures in 2017 were 17.9% of the U.S. gross domestic product ($3.5 trillion). It is projected that by 2027, health care spending will rise to 19.4% of the U.S. gross domestic product.

Although chronic illnesses affect individuals of all ages, they are most prevalent in older people. The most recent U.S. census reported over 40 million people aged 65 and older in the United States. This population is expected to double by 2060, representing more than 20% of the U.S. population. The average person in this age range has two or more chronic conditions, many of which are associated with physical or mental disability. A threefold or greater increase in the disabled elderly population is predicted by the year 2050. The burden of chronic illness also falls disproportionately on poor individuals, educationally disadvantaged people, and ethnic minorities. Several reports document a substantially higher prevalence of health-risk factors (e.g., obesity, cigarette smoking) and selected chronic conditions (diabetes, cardiovascular disease, hypertension, hyperlipidemia) among ethnic minorities in the United States compared with national estimates. Additionally, age and socioeconomic stress factors interact synergistically to increase risk. These figures highlight an urgent need to redesign our health care system and adapt new models of care that will ensure better access and high-quality, affordable, coordinated care for chronic diseases.

A need for coordinated, patient-centered care

Despite recent changes in health care policies such as the Affordable Care Act, the U.S. health care system remains fragmented and poorly organized to meet the challenges of chronic illness care. Care is not patient centered, and it often leaves patients feeling incapable of meeting the day-to-day challenges of living with a chronic condition. In fact, “over 50% of people with chronic illness do not receive modern, evidence-based care.” As described in the 2001 Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, the “current health care system cannot do the job” and “merely making incremental improvements in current systems of care will not suffice.”

Beginning in the mid-1990s, a number of organizations around the country started addressing these challenges. The MacColl Institute of Healthcare Improvement, under the direction of Ed Wagner, MD, MPH, developed a new systematic model for chronic illness care. This model has been introduced and evaluated in a variety of clinical settings nationwide. Data suggest that a more systematic, proactive, patient-centered, and evidence-based approach to care keeps patients with chronic illnesses healthier for longer periods of time. In the Chronic Care Model (CCM), the health needs of patients are met effectively and in a timely manner. In this model, care delivery can be safe, equitable, and efficient for both patients and providers, and morbidity and mortality related to chronic illnesses can be reduced.

Another major development in the coordination of care has been the implementation of the patient-centered medical home (PCMH) concept. The PCMH is a health care model in which a team of health professionals work collaboratively to provide high levels of care coordination and integration as well as quality and safety on an ongoing basis. ^, In the PCMH, health care is coordinated across all elements of the broader health care system. Coordination of care is associated with reduced emergency department visits, hospitalizations, and readmissions for patients with complex care needs, such as older adults. ^, To date, approximately 13,000 practices have transformed into the PCMH model.

Patient-clinician partnerships and team-based care: A paradigm shift in chronic disease management

Chronic disease management requires a patient–clinician partnership and a team-based approach. The patient–clinician partnership requires collaborative care, self-management education, self-efficacy support, and effective communication. In team-based care, patients are active members of the teams that manage their chronic illness. Patients should be part of the decision-making process, they should be able to communicate their preferences and choices, and they should have easy access to their clinics and providers. To improve outcomes and patient satisfaction, clinicians should provide effective self-management support and improved communication among all members of the health care team. This requires innovative solutions, such as coordinating care through health information technology, evidence-based practice, a population-wide approach, and continuous quality improvement initiatives.

The CCM identifies six essential elements needed to improve chronic care within the community and health system. Community factors include resources and policies; health system factors include health care organizations, patient self-management support, delivery system design, decision support tools, and clinical information systems. The goal of the model is to promote “effective change in provider groups to support evidence-based clinical and quality improvement across a wide variety of health care settings.” This goal is accomplished through “productive interactions” between a “prepared, proactive practice team” and an “informed, activated patient,” which in turn will lead to improved health outcomes. The CCM was developed to promote integrated change with components directed at:

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  Influencing provider behavior

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  Better use of nonphysician team members

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  Enhancement of information systems

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  Planned encounters (interactions linked through time to achieve specific goals)

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  Patient self-management

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  Modern self-management support

The CCM incorporates additional themes within the context of the model’s elements: (1) patient safety (Health System), (2) cultural competency (Delivery System), (3) care coordination (Health System and Clinical Information Systems), (4) community policies (Community Resources and Policies), and (5) case management (Delivery System Design). Figure 12.1 illustrates the relational concepts of the Chronic Care and PCMH models.

Elements of the chronic care model

The community creates the context in which health care is delivered. Community programs can support or expand a health system’s ability to care for chronically ill patients. The health care system can enhance care for its patients by forming partnerships to support and develop interventions that fill gaps in needed services and by avoiding the duplication of effort.

Health systems can create an organizational culture and mechanisms that promote safe, high-quality care. Ideally, this culture: “1) visibly supports improvement at all levels of the organization, beginning with the senior leader; 2) promotes effective improvement strategies aimed at comprehensive system change; 3) encourages open and systematic handling of errors and quality problems to improve care; 4) provides incentives based on quality of care (e.g., pay-for-performance, provider incentives); and 5) develops agreements that facilitate care coordination within and across organizations.”

All people make decisions and engage in behaviors that affect their health, and this is no less true for people with chronic illnesses. These behaviors constitute self-management. The outcomes of chronic illness depend largely on the self-management decisions patients make. Effective self-management support prepares patients and their caregivers to manage their health and health care by (1) emphasizing patients’ central roles in managing their health; (2) using strategies that include assessment, goal setting, planning, problem solving, and follow-up; and (3) organizing resources to provide sustainable self-management support.

Improving the health of people with chronic illness requires the creation of a system that is proactive and focused on the promotion of health. This objective is accomplished through the design of delivery systems that ensure effective clinical care and self-management support. This design increases the use of nonphysician team members by defining roles and distributing tasks based on the efficient use of team members’ skills. In a proactive delivery system, there are planned interactions that support evidence-based care. Approaches to these interactions may include (1) longer visits (not necessarily more frequent), (2) an agenda, (3) regular follow-up by the team, and 4) clinical case management services for patients with complex needs. Health literacy and cultural competency are two important concepts in health care. Effective delivery system design includes the ability to respond effectively to the diverse cultural and linguistic needs of patients.

Decision support is essential to the delivery of high-quality, evidence-based care that incorporates patient preferences. In a delivery system with effective decision support, evidence-based guidelines are embedded into daily clinical practice through reminders, feedback, standing orders, and other methods that increase their visibility at the time that clinical decisions are made. Furthermore, these guidelines and information are shared with patients to encourage their participation. For more complex patient care, specialist expertise is integrated into the delivery of primary care.

Effective chronic illness care requires information systems that ensure access to vital data on both individual patients and patient populations. Clinical information systems may be electronic or paper based and are used to organize patient and population data to facilitate care. At the individual level, information systems provide reminders to patients and providers and facilitate individual care planning. At the population level, information systems identify related subpopulations for targeted care and aid in monitoring the performances of providers, the practice team, and the care system.

These six elements combined support productive interactions that are the core of chronic disease management. Note that “interaction” is used deliberately to move away from the idea that all encounters are clinical visits. Phone calls, emails, self-management classes, and support groups are all examples of strategies demonstrated to be effective in improving patient–clinician communication. Half of productive interaction is having a prepared, proactive practice team. To have productive interactions, we need a different kind of team. Also, effective care coordination within health care teams and across facilities and community resources means rethinking the players on the team, their roles, and using all members to full capacity. In addition to the PA, physician, or nurse practitioner, new team members can be added or the roles of existing team members can be expanded. For example, with enhanced training, medical assistants can help with previsit planning, reconcile medications, participate in quality improvement projects, and provide health coaching for patients. Registered nurses (RNs) are ideally suited for direct patient care and leadership roles in PCMHs, based on their education in patient care and family and systems theory. Data show that use of RNs in team-based primary care to provide episodic and preventive care and chronic disease management and to oversee clinical operations such as staff supervision and quality improvement resulted in improved patient outcomes, more productivity, and reduced cost. Seventy-one percent of physician visits involve medication management, including evaluation of therapeutic efficacy, adverse drug events, and potential drug interactions. Studies have demonstrated a correlation between the risk of adverse drug events and nonadherence and the complexity of the medication regimen. ^, This is an opportunity to use the untapped potential of clinical pharmacists to optimize complex therapeutic regimens. Clinical pharmacists perform comprehensive therapy reviews, resolve problems with medications, support adherence and self-management, and recommend economical therapeutic alternatives. In addition to having the right mix of health care professionals, the team must have decision support tools, clinical information systems available at the point of service, and the resources necessary to deliver high-quality care. A crucial member of team-based care, and the other half of the productive interaction, is an informed, activated patient (and caregiver). An informed, activated patient has the knowledge, skills, confidence, and motivation to self-manage care. This requires more than the traditional patient teaching and will be discussed later in this chapter. There is evidence that, with appropriate self-management support, almost any patient can become a relatively effective self-manager. Productive interactions are recognizable by the presence of (1) assessment of self-management skills and confidence as well as clinical status; (2) collaborative definition of problems; (3) collaborative setting of goals and problem solving; (4) the development of a shared care plan; (5) the tailoring of clinical management by stepped protocols and guidelines; and (6) planned, active, and sustained follow-up.