Chronic Care Model Research Articles

Chronic Care Model in Italy: a narrative review of the literature

Abstract Aim: To analyze scientific literature on the development and implementation of the Chronic Care Model (CCM) in treating chronic diseases in the Italy context. Besides, to evaluate the effects of the activities carried out by the operators participating in the CCM on clinical care. Background: Italy is the second country globally for longevity, with 21.4% of citizens over 65 and 6.4% over 80. The CCM fits into this context, a care model aimed primarily at patients suffering from chronic diseases, especially in emergencies, as the recent COVID-19 pandemic. Methods: PubMed, Embase, Scopus, Cinahl, and Cochrane Library scientific databases were consulted, and the records selected as relevant by title and abstract by nine independent scholars, and disagreements were resolved through discussion. Finally, the studies included in this review were selected based on the eligibility criteria. Results: Twenty potentially relevant studies were selected, and after applying the eligibility criteria and screening by the Critical Appraisal Skills Program tool, eight included in this review. The studies showed the effectiveness of CCM for managing patients with heart failure in primary care settings and significant improvements in clinical outcomes, the reduction of inappropriate emergency room access for chronic patients, and the improvement of patients’ overall health with diabetes. The CCM organizational model is effective in improving the management of metabolic control and the main cardiovascular risk factors. Furthermore, this modality also allows doctors to dedicate more space to patients in the disease’s acute phase. Conclusion: The CCM, with its fundamental pillars of empowering self-management of care, could represent a valid alternative to health management. The managers of health services, especially territorial ones, could consider the CCM for the improvement of the treatments offered.

Integrated Care model: Transition from acute to chronic care.

Description and discussion dimensions of Integrated Care Model. A descriptive study is done that describe a technological innovation, intervention strategies for professional performance. Integrated Care Model (ICM) has two main categories include individual and Group-and disease-specific Model. First, is used for risky patients or with comorbidities. In second category; Chronic Care Model (CCM) is common form of Integrated Care Model to improve resultants in the patients with chronic condition, to move from acute care to integrate, regular, long-lasting, preventative and community-based nursing. It is important to consider patient as an active member of the treatment team. It seems to be essential to monitor performance of care system. On the other hand, offer multidisciplinary care leads to present desirable care, tailored to the specific needs of patients regarding safety, patient-centered care and their culture.

Factors that facilitate patient activation in the self-management of diabetes and depression among participants enrolled in an integrated chronic care model in India.

The aim of this study was to identify factors that influence patients' motivation and ability to self-manage their diabetes and depressive symptoms. From 2016 to 17, in-depth interviews were conducted with 62 patients receiving the INDEPENDENT care model across two clinics in India. Using a realist evaluation approach, a hypothesized program theory for patient activation was tested and refined. The refined theory demonstrates that motivation, education, and engagement cumulatively contribute to patient activation. The results indicate that positive and sustained patient-provider relationships drive patient motivation and enhance implementation of the care model.

The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium

BackgroundThe COVID-19 pandemic affects the processes of routine care for chronic patients. A better understanding helps to increase resilience of the health system and prepare adequately for next waves of the pandemic.MethodsA qualitative study was conducted in 16 primary care practices: 6 solo working, 4 monodisciplinary and 7 multidisciplinary. Twenty-one people (doctors, nurses, dieticians) were interviewed, using semi-structured video interviews. A thematic analysis was done using the domains of the Chronic Care Model (CCM).ResultsThree themes emerged: changes in health care organization, risk stratification and self-management support. All participating practices reported drastic changes in organization with a collective shift towards COVID-19 care, and reduction of chronic care activities, less consultations, and staff responsible for self-management support put on hold. A transition to digital support did not occur. Few practitioners had a systematic approach to identify and contact high-risk patients for early follow-up. A practice with a pre-established structured team collaboration managed to continue most chronic care elements. Generally, practitioners expected no effects of the temporary disruption for patients, although they expressed concern about patients already poorly regulated.ConclusionOur findings show a disruption of the delivery of chronic care in the Belgium prim care context. In such contexts, the establishment of the CCM can facilitate continuity of care in crisis times. Short term actions should be directed to facilitate identifying high-risk patients and to develop a practice organization plan to organize chronic care and use digital channels for support, especially to vulnerable patients, during next waves of the epidemic.

Technology-Enabled Health Care Collaboration in Pediatric Chronic Illness: Pre-Post Interventional Study for Feasibility, Acceptability, and Clinical Impact of an Electronic Health Record-Linked Platform for Patient-Clinician Partnership.

BackgroundMobile health (mHealth) technology has the potential to support the Chronic Care Model’s vision of closed feedback loops and patient-clinician partnerships.ObjectiveThis study aims to evaluate the feasibility, acceptability, and short-term impact of an electronic health record–linked mHealth platform (Orchestra) supporting patient and clinician collaboration through real-time, bidirectional data sharing.MethodsWe conducted a 6-month prospective, pre-post, proof-of-concept study of Orchestra among patients and parents in the Cincinnati Children’s Hospital inflammatory bowel disease (IBD) and cystic fibrosis (CF) clinics. Participants and clinicians used Orchestra during and between visits to complete and view patient-reported outcome (PRO) measures and previsit plans. Surveys completed at baseline and at 3- and 6-month follow-up visits plus data from the platform were used to assess outcomes including PRO completion rates, weekly platform use, disease self-efficacy, and impact on care. Analyses included descriptive statistics; pre-post comparisons; Pearson correlations; and, if applicable, effect sizes.ResultsWe enrolled 92 participants (CF: n=52 and IBD: n=40), and 73% (67/92) completed the study. Average PRO completion was 61%, and average weekly platform use was 80%. Participants reported improvement in self-efficacy from baseline to 6 months (7.90 to 8.44; P=.006). At 6 months, most participants reported that the platform was useful (36/40, 90%) and had a positive impact on their care, including improved visit quality (33/40, 83%), visit collaboration (35/40, 88%), and visit preparation (31/40, 78%). PRO completion was positively associated with multiple indicators of care impact at 3 and 6 months.ConclusionsUse of an mHealth tool to support closed feedback loops through real-time data sharing and patient-clinician collaboration is feasible and shows indications of acceptability and promise as a strategy for improving pediatric chronic illness management.

Diabetes care innovation in the Mexican Institute for Social Insurance: Scaling up the preventive chronic disease care model to address critical coverage constraints

BackgroundWith diabetes prevalence in Mexico at 11.3% of adults, the Mexican Institute of Social Insurance (IMSS) is piloting the Chronic Disease Preventive Model (CDPM). CDPM includes intensive patient education, care by multidisciplinary teams and risk management in primary care. The objective of this article is to determine CDPM coverage bottlenecks and to explore facilitators and barriers to implementation. MethodsThe National Health and Nutrition Survey 2018 was processed to identify key diabetes prevalence, coverage, quality and outcome indicators. Key IMSS informant interviews and document content analyses were undertaken following the Tanahashi coverage decay model and the Consolidated Framework for Implementation Research (CFIR). ResultsIMSS screens 49% of adult beneficiaries for diabetes but only 26% with presumptive diagnosis proceed to confirmation. Out of 4.1 million adults with diabetes, IMSS diagnoses 94% and treats 85%. Medications are received by 90% of patients but only 63% of those requiring insulin receive it. The overall quality of care indicator attains 37% of potential. Coverage of diabetes education, monitoring with HbA1c and interdisciplinary care are 20%, 15% and 3%, respectively. Among IMSS beneficiaries treated by the institute 38.1% have HbA1c levels below 7% and 26.1% have levels above 9%. CDPM facilitators are the perceived threat of uncontrolled diabetes, compatibility of innovation values and willingness for institutional learning. Barriers are centralized decision making, functional differentiation across managers and practitioners and lack of incentives, resource shortages and the lack of measures to ensure fidelity. ConclusionsCDPM scale-up has to address organizational and process barriers while ensuring the necessary resources for sustainability.

Seek, and ye shall find: Efficacy of proactive screeningfor diabetic foot ulceration in the community autonomously performed by nurses

Diabetic foot ulceration (DFU) is a severe complication of diabetes mellitus associated with a high morbidity and mortality rate, whose treatment requires considerable financial costs. This paper describes a test of the efficacy of proactive screening – autonomously managed by nurses in a community setting – in detecting patients at high risk of DFU, as an integrated part of a chronic care model strategy.

The complex pa¬tient with diabetes and cardio-renal comorbidities: a mana¬gement model proposal

Type 2 diabetes mellitus (DM) is a metabolic disorder and its prevalence has been increasing in the world population and represents one of the chronic diseases with the highest socioeconomic impact on the health systems. It is expected that in the next decade life expectancy and population aging will increase with the consequences of the increasing incidence of diabetes and its associated comorbidities. (DM) is the main cause of chronic kidney disease and it is associated with a significant increasing in cardiovascular risk. The coexistence of cardiac and kidney diseases on a metabolic basis, named “cardiorenal metabolic syndrome”, in elderly patients affected by multimorbidity increase their clinical and care complexity. In order to assess clinical complexity it is necessary to change paradigm from a reactive approach to a proactive one and the integration of territorial, hospital and social services according to the Chronic Care Model (CCM) is important. The proactive management of the complex patient suffering from chronic diseases and multimorbidity has been implemented at the National ARNAS Civico Hospital in Palermo with the MUSE (Multidimensional aSsessment of Elderly) project. The interaction between hospital and territorial services to respond to patients’ needs should be a priority. The hospital must therefore be conceived as a highly specialized center for chronic disease management that works with primary care according to a multidimensional and multidisciplinar model of care reducing rehospitalization and negative outcomes in patients affected by chronic diseases. KEY WORDS diabetes mellitus type2; comorbidity; management model; complexity; cardiorenal syndrome.

The burden of treatment in people living with type 2 diabetes: A qualitative study of patients and their primary care clinicians.

BackgroundThe burden of treatment can overwhelm people living with type 2 diabetes and lead to poor treatment fidelity and outcomes. Chronic care programs must consider and mitigate the burden of treatment while supporting patients in achieving their goals.ObjectiveTo explore what patients with type 2 diabetes and their health providers consider are the workload and the resources they must mobilize, i.e., their capacity, to shoulder it.MethodsWe conducted focus groups comprised of 30 patients and 32 clinicians from three community health centers in Chile implementing the Chronic Care Model to reduce cardiovascular risk in patients with type 2 diabetes. Transcripts were analyzed using thematic content analysis techniques illuminated by the Minimally Disruptive Medicine framework.FindingsGaining access to and working with their clinicians, implementing complex medication regimens, and changing lifestyles burdened patients. To deal with the distress of the diagnosis, difficulties achieving disease control, and fear of complications, patients drew capacity from their family (mostly men), social environment (mostly women), lay expertise, and spirituality. Clinicians found that administrative tasks, limited formulary, and protocol rigidity hindered their ability to modify care plans to reduce patient workload and support their capacity.ConclusionsChronic primary care programs burden patients living with type 2 diabetes while hindering clinicians’ ability to reduce treatment workloads or support patient capacity. A collaborative approach toward Minimally Disruptive Medicine may result in treatments that fit the lives and loves of patients and improve outcomes.

Comparative effectiveness of external vs blended facilitation on collaborative care model implementation in slow-implementer community practices.

To evaluate the comparative effectiveness of external facilitation (EF) vs external+internal facilitation (EF/IF), on uptake of a collaborative chronic care model (CCM) in community practices that were slower to implement under low-level implementation support. Primary data were collected from 43 community practices in Michigan and Colorado at baseline and for 12months following randomization. Sites that failed to meet a pre-established implementation benchmark after six months of low-level implementation support were randomized to add either EF or EF/IF support for up to 12months. Key outcomes were change in number of patients receiving the CCM and number of patients receiving a clinically significant dose of the CCM. Moderators' analyses further examined whether comparative effectiveness was dependent on prerandomization adoption, number of providers trained or practice size. Facilitation log data were used for exploratory follow-up analyses. Sites reported monthly on number of patients that had received the CCM. Facilitation logs were completed by study EF and site IFs and shared with the study team. N=21 sites were randomized to EF and 22 to EF/IF. Overall, EF/IF practices saw more uptake than EF sites after 12months (ΔEF/IF-EF =4.4 patients, 95% CI=1.87-6.87). Moderators' analyses, however, revealed that it was only sites with no prerandomization uptake of the CCM (nonadopter sites) that saw significantly more benefit from EF/IF (ΔEF/IF-EF =9.2 patients, 95% CI: 5.72, 12.63). For sites with prerandomization uptake (adopter sites), EF/IF offered no additional benefit (ΔEF/IF-EF =-0.9; 95% CI: -4.40, 2.60). Number of providers trained and practice size were not significant moderators. Although stepping up to the more intensive EF/IF did outperform EF overall, its benefit was limited to sites that failed to deliver any CCM under the low-level strategy. Once one or more providers were delivering the CCM, additional on-site personnel did not appear to add value to the implementation effort.

Positive deviants for medication therapy management: A mixed-methods comparative case study of community pharmacy practices.

To optimize medication use in older adults, the Centers for Medicare & Medicaid Services (CMS) launched Medication Therapy Management (MTM) services as part of Medicare Part D policy; however, strategies for achieving high quality MTM outcomes are not well understood. The objective of this study was to generate hypotheses for strategies contributing to community pharmacies' high performance on policy-relevant MTM quality measures. This mixed-methods comparative case study was guided by the Positive Deviance approach and Chronic Care Model. The study population consisted of pharmacy staff employed by a Midwestern division of a national supermarket-community pharmacy chain. Data consisted of demographics and qualitative data from semi-structured interviews. Qualitative and quantitative data were analyzed deductively and inductively or using descriptive statistics, respectively. MTM quality measures used to evaluate participant pharmacies' MTM performance mirrored select 2017 Medicare Part D Plans' Star Rating measures. Thirteen of 18 selected case pharmacies (72.2%) participated in this study, of which 5 were categorized as high performers, 4 moderate performers, and 4 low performers. Eleven pharmacists, 11 technicians, and 3 student interns participated in interviews. Eight strategies were hypothesized as contributing to MTM performance: Strong pharmacy staff-provider relationships and trust, Inability to address patients' social determinants of health (negatively contributing), Technician involvement in MTM, Providing comprehensive medication reviews in person vs. phone alone, Placing high priority on MTM, Using available clinical information systems to identify eligible patients, Technicians using clinical information systems to collect/document information for pharmacists, Faxing prescribers adherence medication therapy problems (MTPs) and calling on indication MTPs. Eight strategies were hypothesized as contributing to community pharmacies' performance on MTM quality measures. Findings from this work can inform MTM practice and Medicare Part D MTM policy changes to positively influence patient outcomes. Future research should test hypotheses in a larger representative sample of pharmacies.

Back to the Hospital for Chronic Care: a Hybrid Generalist Model

Singapore, like many countries, is attempting to meet the growing healthcare needs of an ageing population with a high burden of chronic diseases. Despite efforts to integrate and increase healthcare capacity, longstanding challenges remain difficult to overcome. Recently, policymakers have considered a new approach to building chronic and eldercare capacity-the Integrated General Hospital (IGH). The development of the IGH model is motivated by a combination of factors: the limit to which the primary care system can manage patients with increasingly complex chronic diseases, a longstanding preference of patients for hospital-based specialty services and patients experiencing fragmented care delivery. The IGH model links hospital care teams and community-based care providers, to facilitate the management of patients throughout the care continuum in a single integrated site. It is hoped that this hospital-led model for chronic care can meet patients' needs and preferences and reduce fragmentation of care.

Finding a Medical Home for Perinatal Depression: How Can We Bridge the Postpartum Gap?

Finding a Medical Home for Perinatal Depression: How Can We Bridge the Postpartum Gap?

Challenges in the Management of Diabetes in Primary Care

Diabetes management in primary care is critical to reducing the occurrence and severity of complications through blood sugar management and early detection. A chronic disease management in primary care pilot project, based on the Chronic Care Model (CCM) model that provides patient education on, regular monitoring blood glucose level, medication intake, healthy lifestyle practice, and complications has been developed and applied. Primary care in Korea should provide appropriate education to patients with diabetes and increase the rate of complication testing. In addition, it is of the utmost importance to establish an infrastructure for medical staff to manage patients on a team basis and to establish a patient management system in the community by strengthening primary center (private) and public health care center (public) cooperation activities. Keywords: Care coordinator, Chronic Care Model, Diabetes management in primary center, Private-public cooperation

Measuring Implementation Strategy Fidelity in HealthyHearts NYC: A Complex Intervention Using Practice Facilitation in Primary Care.

Few studies have assessed the fidelity of practice facilitation (PF) as an implementation strategy, and none have used an a priori definition or conceptual framework of fidelity to guide fidelity assessment. The authors adapted the Conceptual Framework for Implementation Fidelity to guide fidelity assessment in HealthyHearts NYC, an intervention that used PF to improve adoption of cardiovascular disease evidence-based guidelines in primary care practices. Data from a web-based tracking system of 257 practices measured fidelity using 4 categories: frequency, duration, content, and coverage. Almost all (94.2%) practices received at least the required 13 PF visits. Facilitators spent on average 26.3 hours at each site. Most practices (95.7%) completed all Task List items, and 71.2% were educated on all Chronic Care Model strategies. The majority (65.8%) received full coverage. This study provides a model that practice managers and implementers can use to evaluate fidelity of PF, and potentially other implementation strategies.

Factors Associated With Participation in the Chronic Disease Self-Management Program: Findings From the SUCCEED Trial.

Self-management programs may improve quality of life and self-efficacy for stroke survivors, but participation is low. In a randomized controlled trial of a complex, multidisciplinary, team-based secondary stroke prevention intervention, we offered participants Chronic Disease Self-Management Program (CDSMP) workshops in addition to clinic visits and home visits. To enhance participation, workshops were facilitated by community health workers who were culturally and linguistically concordant with most participants and scheduled CDSMP sessions at convenient venues and times. Over time, we implemented additional strategies such as free transportation and financial incentives. In this study, we aimed to determine factors associated with CDSMP participation and attendance. From 2014 to 2018, 18 CDSMP workshop series were offered to 241 English and Spanish-speaking individuals (age ≥40 years) with recent stroke or transient ischemic attack. Zero-inflated Poisson regression was used to identify factors associated with participation and attendance (ie, number of sessions attended) in CDSMP. Missing values were imputed using multiple imputation methods. Nearly one-third (29%) of intervention subjects participated in CDSMP. Moderate disability and more clinic/home visits were associated with participation. Participants with higher numbers of clinic and home visits (incidence rate ratio [IRR], 1.06 [95% CI, 1.01-1.12]), severe (IRR, 2.34 [95% CI, 1.65-3.31]), and moderately severe disability (IRR, 1.55 [95% CI, 1.07-2.23]), and who enrolled later in the study (IRR, 1.12 [95% CI, 1.08-1.16]) attended more sessions. Individuals with higher chaos scores attended fewer sessions (IRR, 0.97 [95% CI, 0.95-0.99]). Less than one-third of subjects enrolled in the SUCCEED (Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities) intervention participated in CDSMP; however, participation improved as transportation and financial barriers were addressed. Strategies to address social determinants of health contributing to chaos and engage individuals in healthcare may facilitate attendance. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01763203.

Feasibility and preliminary outcomes of an integrated pediatric sickle cell disease and pulmonary care clinic for children with sickle cell disease.

In children with sickle cell disease (SCD), comorbid asthma is associated with increased disease severity and morbidity, but it remains underdiagnosed and optimal management paradigms are not well defined. The purpose of this study was to determine the feasibility and preliminary outcomes of an integrated pediatric SCD and pulmonary care clinic in children with SCD. We implemented a pre-post quality improvement (QI) project in our pediatric hematology clinic between 2017 and 2019. Guided by the chronic care model, patients who were ages 2-18years, diagnosed with SCD and suspected pulmonary comorbidities, received care in an interdisciplinary clinic. We examined feasibility and compared clinical outcomes to 24months prior (2015-2017) to the implementation of the integrated care model. Twenty-four patients were included in the QI project: 88% (n=21) received pulmonary function testing, 92% (n=22) were diagnosed with asthma, and 33% (n=8) with obstructive sleep apnea. Adherence to pulmonary appointments was increased by 81% (mean difference [MD]=1.3, 95% confidence interval [CI]=0.71-1.92; P<.001). Unplanned acute health care utilization was reduced by 59% (MD=2.9, 95% CI=1.14-4.69; P<.01) and packed red blood cell transfusion was reduced by 81% (MD=1.38, 95% CI=0.71-2.04; P<.001). Asthma is prevalent in children with SCD, and interdisciplinary clinics can improve access to subspecialty pulmonary care and reduce unplanned acute care. Additional patients and a longer follow-up period are required to determine the true treatment effect.

Enhanced Care Team Nurse Process to Improve Diabetes Care.

Collaborative practice models such as the Chronic Care Model are particularly relevant for integrated health care delivery systems, accountable care organizations, and patient-centered medical homes, which focus on improving population health and reducing costs of care.1,2 Our team has developed an

Improving continuity of care of patients with respiratory disease at hospital discharge.

Continuity of care refers to the delivery of coherent, logical and timely care to an individual. It is threatened during the transition of care at hospital discharge, which can contribute to worse patient outcomes. In a traditional acute care model, the roles of hospital and community healthcare providers do not overlap and this can be a barrier to continuity of care at hospital discharge. Furthermore, the transition from inpatient to outpatient care is associated with a transition from acute to chronic disease management and, in a busy hospital, attention to this can be crowded out by the pressures of providing acute care. This model is suboptimal for the large proportion of patients admitted to hospital with acute-on-chronic respiratory disease.In a chronic care model, the healthcare system is designed to give adequate priority to care of chronic disease. Integrated care for the patient with respiratory disease fits the chronic care model and responds to the fragmentation of care in a traditional acute care model: providers integrate their respiratory services to provide continuous, holistic care tailored to individuals. This promotes greater continuity of care for individuals, and can improve patient outcomes both at hospital discharge and more widely.Educational aimsTo understand the concept of continuity of care and its effect at the transition between inpatient and outpatient care.To understand the difference between the acute and chronic models of healthcare.To understand the effect of integration of care on continuity of care for patients with respiratory disease and their health outcomes.

Care Manager nurse for chronic patients in primary care: a literature review

Abstract Background The reorganization of home care provides nurses the opportunity to move to a role of “Care Manager”, affording a more effective management of chronic patients. This study aims to investigate whether the introduction of this new nursing role improved care related outcomes in people with one or more chronic conditions in primary care setting. Methods Articles considered for this review had to assess the outcomes obtained from outpatient care and home care in which the care manager nurse had been involved. Literature search was performed in PubMed, Cinahl, Scopus, Cochrane, and Google Scholar. Results 20 studies have been selected. Care manager was introduced mainly into the American healthcare systems (80%) and only partly in the European ones (20%). Nurse provided outpatient care (95%) and home care (75%) dealing with the development of the care plan, therapeutic education and proactive prevention. The interventions were based on three fundamental principles of the Chronic Care Model: care teams, self-care support, computerized information system. The health outcomes achieved include: reduction of health care costs, hospital admissions and mortality rates; improvements of disease-specific clinical parameters and quality of life, and an excellent level of satisfaction on patients' and healthcare professionals' side (perceived quality of care). Conclusions The literature shows that nursing interventions carried out by the care manager in collaboration with other primary care professionals provided positive results in many ways. Key messages The reorganization of home care provides nurses the opportunity to take the role of “Care Manager”. This figure could afford a more effective management of chronic patients. Nurse provided outpatient care (95%) and home care (75%) dealing with the development of the care plan, therapeutic education and proactive prevention. These interventions led to positive results.