A New Model For Chronic-Care Delivery

Abstract

RISING HEALTHCARE COSTS, increasing numbers of patients with chronic illnesses, an aging population, and a healthcare delivery system failing to meet the needs of its people - this could describe American medicine in the 1980s and 1990s. American medicine was then based on an acute-care model, where a patient presented with a set of signs and symptoms, the physician made the appropriate diagnosis and prescribed the treatment, and the patient received the treatment and returned home. The acute-care model was not designed for patients with chronic disease. Recognizing that the acute-care model was not working, many healthcare workers and policy makers proposed alternative or supplemental programs to address its deficiencies, such as expanding managed and instituting disease-management and case-management programs, but they never fundamentally addressed the delivery of healthcare to the patient. Wagner and colleagues proposed a new way to improve chronic illness that addressed healthcare delivery, based on their Chronic Care Model. The Chronic Care Model, which celebrates its tenth anniversary this year, was a comprehensive change to the way healthcare is delivered to patients with chronic conditions (Wagner 1996, 1998). The model focuses on several aspects of the healthcare organization. Healthcare delivery would evolve from a simple doctor-patient relationship where the physician told the patient what to do - to a more collaborative process between an informed patient and a prepared, proactive healthcare team. The healthcare team works within an organized system, where healthcare is evidence-based, systems are in place to measure and track outcomes, and information is fed back to patients and physicians. In this system patients are proactively followed (as opposed to the system reacting to patient demand), patients are empowered to self manage their disease, and the healthcare system works with its surrounding community. These elements have gradually begun to be adopted nationally. PATIENT-CENTERED MEDICAL HOME Another approach to improving chronic illness that has been gaining support is the patient-centered medical home. The medical home is a model of healthcare delivery that focuses on an ongoing relationship between patients and their providers in a comprehensive healthcare delivery system (Iglehart 2008). The concept predates the Chronic Care Model and was originally proposed by the American Academy of Pediatrics (AAP) in the late 1960s. It focused on having a unified medical record for children with special healthcare needs, who were often treated by multiple providers who did not communicate well among themselves (Sia 2004). By 1992, the AAP broadened the concept by stating that the healthcare should be directed by well-trained physicians who provide primary care (Medical Home Initiatives for Children with Special Needs Project Advisory Committee 2002). In February 2007, the AAP, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association issued a joint statement supporting the adoption of the patient centered medical home (AAFP 2007). They agreed that in a medical home: (1) each patient should have a personal physician who provides continuous and comprehensive care; (2) the physician should lead a practice-level team that assists in providing ongoing for the patient; (3) should be person-and family-oriented and include for all stages of life; (4) should be coordinated and integrated across both the healthcare system and the patient's community where the appropriate use of health information technology will ensure that information is available when and where it is needed; (5) is evidencebased with ongoing measurement of quality, active feedback of information to healthcare providers, patient education, and involvement of the patient in decision-making; (6) improved patient access to and communication with their healthcare team; and (7) payment reform, including payments for coordination and non-face-to-face visits. …