Chronic Disease Management Model Research Articles

Outcomes and opportunities: a nurse-led model of chronic disease management in Australian general practice

The Australian government's commitment to health service reform has placed general practice at the centre of its agenda to manage chronic disease. Concerns about the capacity of GPs to meet the growing chronic disease burden has stimulated the implementation and testing of new models of care that better utilise practice nurses (PN). This paper reports on a mixed-methods study nested within a larger study that trialled the feasibility and acceptability of a new model of nurse-led chronic disease management in three general practices. Patients over 18 years of age with type 2 diabetes, hypertension or stable ischaemic heart disease were randomised into PN-led or usual GP-led care. Primary outcomes were self-reported quality of life and perceptions of the model's feasibility and acceptability from the perspective of patients and GPs. Over the 12-month study quality of life decreased but the trend between groups was not statistically different. Qualitative data indicate that the PN-led model was acceptable and feasible to GPs and patients. It is possible to extend the scope of PN care to lead the routine clinical management of patients' stable chronic diseases. All GPs identified significant advantages to the model and elected to continue with the PN-led care after our study concluded.

Understanding the process of patient satisfaction with nurse‐led chronic disease management in general practice

To investigate the process of patient satisfaction with nurse-led chronic disease management in Australian general practice. Nurses working in the primary care context of general practice, referred to as practice nurses, are expanding their role in chronic disease management; this is relatively new to Australia. Therefore, determining patient satisfaction with this trend is pragmatically and ethically important. However, the concept of patient satisfaction is not well understood particularly in relation to care provided by practice nurses. A grounded theory study underpinned by a relativist ontological position and a relativist epistemology. Grounded theory was used to develop a theory from data collected through in-depth interviews with 38 participants between November 2007-April 2009. Participants were drawn from a larger project that trialled a practice nurse-led, collaborative model of chronic disease management in three Australian general practices. Theoretical sampling, data collection, and analysis were conducted concurrently consistent with grounded theory methods. Patients undergo a cyclical process of Navigating Care involving three stages, Determining Care Needs, Forming Relationship, and Having Confidence. The latter two processes are inter-related and a feedback loop from them informs subsequent cycles of Determining Care Needs. If any of these steps fails to develop adequately, patients are likely to opt out of nurse-led care. Navigating Care explains how and why time, communication, continuity, and trust in general practitioners and nurses are important to patient satisfaction. It can be used in identifying suitable patients for practice nurse-led care and to inform the practice and organization of practice nurse-led care to enhance patient satisfaction.

Re-imagining Healthcare: The Northwest Territories Transitions to an Integrated Chronic Disease Management Strategy

With the goal to improve healthcare services and delivery, Stanton Territorial Hospital in the Northwest Territories (NWT) invited the Canadian Health Services Research Foundation (CHSRF) to explore opportunities to collaborate in the redesign and improvement of the health system. This article describes the NWT’s efforts to transform its healthcare delivery to more appropriately care for people living with chronic diseases. It also sets the context for the initial meeting between the NWT and CHSRF and the collaborative journey that continues, with the bringing together of 40 health system managers, policy makers and clinicians, along with CHSRF staff and guest faculty, with a shared vision to redesign care to better meet the needs of people living with chronic diseases in the territory. In the NWT, chronic diseases account for approximately 70% of all deaths and half of all hospital admission days (Northwest Territories Department of Health and Social Services [DHSS] 2011b). As elsewhere, it is understood that healthcare services are not currently meeting population needs. Canadian health systems rank poorly in international comparisons that focus on the delivery of primary care, especially to those with multiple chronic conditions (Schoen et al. 2009). It is also well recognized in Canada that few healthcare systems are patient centred. In a recently commissioned CHSRF synthesis on transformation, professors Ross Baker and Jean-Louis Denis (2011) remarked, “Healthcare systems tend to reproduce their dominant logic and consequently neglect other areas where major care deficits persist.” In another CHSRF-commissioned synthesis on transformation, Professor Denis and colleagues (2011) noted that “a clear vision and a coherent set of strategies are required to transform the system and achieve better alignment between the care offered and the care the population needs today.” Such is the challenge for the NWT. In its recently released 2011–2016 strategic plan, DHSS (2011a) set a priority to “improve the health status of the population” through the development of a culturally appropriate chronic disease management model that tracks system quality outcome measures. With a senior leadership dedicated to improving the health status of its population as a key strategic priority and highly engaged throughout the change management process, the NWT is well positioned to improve healthcare services and delivery through transformation. CHSRF, in partnership with NWT leadership, intends to support the territory through its longer-term vision, to strategically reorient the health system for the benefit of all those living in the territory. We also hope that the lessons we learn here hold value for learning elsewhere.

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A Consensus-Based Policy Framework on Pharmacist-Led Self-Management Using the Delphi Process

Fragmentation of the healthcare system and lack of connectivity between in-hospital and community services, have posed an impact on management of patients with chronic conditions. As self-management is an essential component in chronic disease management model and pharmacists are underutilized in Hong Kong, this study developed a consensus-based policy framework on pharmacist-led self-management using a Delphi panel consisted of medical doctors, pharmacists, Chinese medicine practitioners and dispensers. We had studied a local population survey to understand the use of over-the-counter medication, conducted focus groups and telephone survey to explore the views of the four health professions and the general population, respectively, on pharmacist-led approach in self-management. The find- ings served as the base for developing the self-administered questionnaire in Delphi. A total of 19 experts completed the questionnaires and rated the validity and clarity of each statement in a 9-point scale. The Delphi process was completed in two rounds. Community pharmacists could only play an assisting role in patient self-management. They should focus primarily on drug-related issues and were suggested to work on lifestyle modifications collaboratively with physicians and nurses. The government has to develop supportive measures to enhance pharmacist-led patient self-management in the future.

The nursing contribution to chronic disease management: A case of public expectation? Qualitative findings from a multiple case study design in England and Wales

Background The global response to the rise in prevalence of chronic disease is a focus on the way services are managed and delivered, in which nurses are seen as central in shaping patient experience. However, there is relatively little known on how patients perceive the changes to service delivery envisaged by chronic care models. Objectives The PEARLE project aimed to explore, identify and characterise the origins, processes and outcomes of effective chronic disease management models and the nursing contributions to the models. Design, settings and participants Case study design of seven sites in England and Wales ensuring a range of chronic disease management models. Participants included over ninety patients and family carers ranging in age from children to older people with conditions such as diabetes, respiratory disease, epilepsy, or coronary heart disease. Methods Semi-structured interviews with patients and family carers. Focus groups were conducted with adolescents and children. A whole systems approach guided data collection and data were thematically analysed. Results Despite nurses’ role and skill development and the shift away from the acute care model, the results suggested that patients had a persisting belief in the monopoly of expertise continuing to exist in the acute care setting. Patients were more satisfied if they saw the nurse as diagnostician, prescriber and medical manager of the condition. Patients were less satisfied when they had been transferred from an established doctor-led to nurse-led service. While nurses within the study were highly skilled, patient perception was guided by the familiar rather than most appropriate service delivery. Most patients saw chronic disease management as a medicalised approach and the nursing contribution was most valued when emulating it. Conclusions Patients’ preferences and expectations of chronic disease management were framed by a strongly biomedical discourse. Perceptions of nurse-led chronic disease management were often shaped by what was previously familiar to the patient. At a strategic level, autonomous nursing practice requires support and further promotion to wider society if there is to be a shift in societal expectation and trust in the nurse's role in chronic disease management.

Patient, practice and organisational influences on asthma control: Observational data from a national study on primary care in the United Kingdom

BackgroundAchieving asthma control is central to optimising patient quality of life and clinical outcome. Contemporary models of chronic disease management across a variety of countries point to the importance of micro, meso and macro level influences on patient care and outcome. However, asthma outcomes research has almost invariably concentrated on identifying and addressing patient predictors. Little is known about higher level organisational influences. ObjectiveThis paper explores the contribution of organisational factors on poor asthma control, allowing for patient factors, at three organisational levels: the individual patient, local service deliverers, and strategic regional providers. Design, setting and participantsProspective cross-sectional observational cohort study of 64,929 people with asthma from 1205 primary care practices spread throughout the United Kingdom (UK). Patient clinical data were recorded during a routine asthma review. MethodData were analysed using simple descriptive, multiple regression and complex multi-level modelling techniques, accounting for practice clustering of patients. ResultsPoor asthma control was associated with areas of higher deprivation [regression coefficient 0.026 (95% confidence intervals 0.006; 0.046)] and urban practice [−0.155 (−0.275; −0.035)] but not all local and regional variation was explained by the data. In contrast, patient level predictors of poor control were: short acting bronchodilator overuse [2.129 (2.091; 2.164)], days-off due to asthma [1.203 (1.148; 1.258)], PEFR<80 [0.76 (0.666; 0.854)], non-use of a self-management plan (SMP) [0.554 (0.515; 0.593)], poor inhaler technique [0.53 (0.475; 0.585)], poor medication compliance [0.385 (−0.007; 0.777)], and gender [0.314 (0.281; 0.347)]. Pattern of medication use, smoking history, age, body mass index (BMI), and health service resource use were also significant factors for predicting control. ConclusionsTargeting of health service resource requires knowledge of the factors associated with poor control of asthma symptoms. In the UK the contribution of local and regional structures appears minimal in explaining variation in asthma outcomes. However, unexplained variation in the data suggests other unrecorded factors may play a part. While patient personal characteristics (including self-management plan use, inhaler technique, medication compliance) appear to be the predominant influence the complex nature of the disease means that some, perhaps more subtle, influences are affecting the variability at all levels and this variance needs to be explored. Further research in other international contexts is required to identify the likely applicability of these findings to other health care systems.

How and when eHealth is a good investment for patients managing chronic disease

In this article, we elaborate on the cost-effectiveness of eHealth solutions and the need to evaluate the return on investment as is done routinely with all other major expenditures. To this end, we discuss the theory that exists today to explain some of the usage principles affiliated with information technology implementation in healthcare; namely, we reflect on the Technology Adoption Criteria in Health (TEACH) model and Wagner's Chronic Disease Management model. The basic premise of the TEACH model is that adoption requires work; this work must be recognized at the outset, and the progress to overcome the workload increase must be measured for the adoption to continue. Furthermore, both of these models have emphasized that the trade-off between cost and work and the benefits realized (as seen through measurement) must first be applied to patients that use the system frequently and on an ongoing basis (ie, the chronically ill). We refer to these ongoing users as consumers of healthcare resources-Consumers with Chronic Conditions (the 3C patients). In this article, we show that the benefits outweigh the costs only when we do, in fact, apply the analysis to 3C patients. Once an effective eHealth system has been developed for the 3C patients, then it can be straightforwardly extended to include all patients and other stakeholders.

Goal Setting Education and Counseling Practices of Diabetes Educators

The purpose of this study was to identify goal setting education practices used by diabetes educators working with type 2 diabetes patients. Data were collected by a mail questionnaire with 179 diabetes educators purposively selected from the 2008 American Association of Diabetes Educators membership listing. Many diabetes educators (52%) reported that more than 75% of their patients set goals for diabetes control. Independent factor patterns for the frequency of information collected from the patient for the first diabetes education session showed that educators either focused on patients' self-management practices (exercise and dietary practices, knowledge, and social impacts of diabetes) or issues with learning about self-management, such as understanding the patient's learning style and motivation for managing diabetes. Factor patterns overall showed diverse approaches to working with patients, including strategies used with patients struggling with dietary goals and the importance of tasks to complete during the first patient session. Although most educators reported practices that were largely patient centered as promoted by the American Diabetes Association (ADA) and models of chronic disease management, patterns of practice suggest that diabetes educators vary considerably in how they apply education practices, especially with dietary self-management education.

Cost-Effectiveness Analysis of a Randomized Trial Comparing Care Models for Chronic Kidney Disease

Potential cost and effectiveness of a nephrologist/nurse-based multifaceted intervention for stage 3 to 4 chronic kidney disease are not known. This study examines the cost-effectiveness of a chronic disease management model for chronic kidney disease. Cost and cost-effectiveness were prospectively gathered alongside a multicenter trial. The Canadian Prevention of Renal and Cardiovascular Endpoints Trial (CanPREVENT) randomized 236 patients to receive usual care (controls) and another 238 patients to multifaceted nurse/nephrologist-supported care that targeted factors associated with development of kidney and cardiovascular disease (intervention). Cost and outcomes over 2 years were examined to determine the incremental cost-effectiveness of the intervention. Base-case analysis included disease-related costs, and sensitivity analysis included all costs. Consideration of all costs produced statistically significant differences. A lower number of days in hospital explained most of the cost difference. For both base-case and sensitivity analyses with all costs included, the intervention group required fewer resources and had higher quality of life. The direction of the results was unchanged to inclusion of various types of costs, consideration of payer or societal perspective, changes to the discount rate, and levels of GFR. The nephrologist/nurse-based multifaceted intervention represents good value for money because it reduces costs without reducing quality of life for patients with chronic kidney disease.

Patient self-management and pharmacist-led patient self-management in Hong Kong: A focus group study from different healthcare professionals' perspectives

BackgroundPatient self-management is a key approach to manage non-communicable diseases. A pharmacist-led approach in patient self-management means collaborative care between pharmacists and patients. However, the development of both patient self-management and role of pharmacists is limited in Hong Kong. The objectives of this study are to understand the perspectives of physicians, pharmacists, traditional Chinese medicine (TCM) practitioners, and dispensers on self-management of patients with chronic conditions, in addition to exploring the possibilities of developing pharmacist-led patient self-management in Hong Kong.MethodsParticipants were invited through the University as well as professional networks. Fifty-one participants comprised of physicians, pharmacists, TCM practitioners and dispensers participated in homogenous focus group discussions. Perspectives in patient self-management and pharmacist-led patient self-management were discussed. The discussions were audio recorded, transcribed and analysed accordingly.ResultsThe majority of the participants were in support of patients with stable chronic diseases engaging in self-management. Medication compliance, monitoring of disease parameters and complications, lifestyle modification and identifying situations to seek help from health professionals were generally agreed to be covered in patient self-management. All pharmacists believed that they had extended roles in addition to drug management but the other three professionals believed that pharmacists were drug experts only and could only play an assisting role. Physicians, TCM practitioners, and dispensers were concerned that pharmacist-led patient self-management could be hindered, due to unfamiliarity with the pharmacy profession, the perception of insufficient training in disease management, and lack of trust of patients.ConclusionsAn effective chronic disease management model should involve patients in stable condition to participate in self-management in order to prevent health deterioration and to save healthcare costs. The role of pharmacists should not be limited to drugs and should be extended in the primary healthcare system. Pharmacist-led patient self-management could be developed gradually with the support of government by enhancing pharmacists' responsibilities in health services and developing public-private partnership with community pharmacists. Developing facilitating measures to enhance the implementation of the pharmacist-led approach should also be considered, such as allowing pharmacists to access electronic health records, as well as deregulation of more prescription-only medicines to pharmacy-only medicines.

Improvement in Global Psychopathology Increases Quality of Life During Treatment of ADHD with Atomoxetine or Stimulants

To evaluate what determines the increase in quality of life during treatment for ADHD: improvement in core ADHD symptoms or improvement in global psychopathology ratings. A prospective follow-up of ADHD patients in one community clinic. Standardized evaluation and outcome measures were used, including the Mini International Neuropsychiatric Interview, Child Symptom Inventory, 18 item ADHD rating scale, and the Health and Life Functioning Scale. 75 patients between the ages of 6 and 12 were treated with atomoxetine or stimulants with a stable dose for 10months. At end point, there were modest improvements in ADHD symptoms, global psychopathology, level of functioning and quality of life. The improvement in quality of life was driven by a decrease in global psychopathology, not by a decrease in ADHD symptoms. The treatment for ADHD may need to be broadened beyond the core symptoms. A chronic disease management model may well be applicable.

“They Don't Want Anything to Do with You”: Patient Views of Primary Care Management of Chronic Pain

Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care. Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used structured questions and were tape recorded, transcribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish. Convenience sample of 72 adult patients (68% female, 44% Latino, mean age=48.1 years) recruited from four diverse primary care practices in Central Massachusetts. Across all 17 groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their providers when seeking care for chronic pain. Subjects acknowledged feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care. Patients reported more satisfaction when they felt a provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. Patients also recommended some management techniques related to the chronic disease management model to improve pain care. Implementing patient-centered approaches in caring for individuals with chronic pain and using principles drawn from the chronic disease management model to improve care systems may improve both patient and provider satisfaction with chronic pain care.

Consensus Statement: The Development of a National Canadian Migraine Strategy

Migraine is a significant cause of suffering and disability in the Canadian population, and imposes a major cost on Canadian Society. Based on current medical science, much more could be done to provide better comprehensive medical care to the millions of individuals with migraine in Canada. To propose and design a national Canadian Migraine Strategy which could be implemented to reduce migraine related disability in Canada. A multidisciplinary task force of the Canadian Headache Society met for a Canadian Migraine Summit Meeting in Halifax, Nova Scotia in June, 2009. Pertinent literature was reviewed and a consensus document was produced based upon the round table discussion at the meeting. The outline of a national Canadian Migraine Strategy was created. This strategy is based on the chronic disease management model, and would include: an outline of what constitutes appropriate migraine care for Canadians, educational programs (for health care professionals, individuals with migraine, and the general public), research programs, and the development of the necessary organizations and partnerships to develop further and implement the Canadian Migraine Strategy. Based upon the medical literature and expert discussion at the meeting, a national Canadian Migraine Strategy with a patient self-management focus has the potential to improve patient care and reduce headache related disability in Canada.

Will We Better Manage Chronic Disease?

Will We Better Manage Chronic Disease?

CareBeyond: A Chronic Disease Management Model in Hospice Care for COPD Patients (407)

CareBeyond: A Chronic Disease Management Model in Hospice Care for COPD Patients (407)

Primary Immunodeficiency Disease

Patient-centered chronic care management is a new model for the management of rare chronic diseases such as primary immunodeficiency disease (PIDD). This approach emphasizes helping patients become experts on the management of their disease as informed, involved, and interactive partners in healthcare decisions with providers. Because only a few patients are affected by rare illnesses, these patients are forced to become knowledgeable about their disease and therapies and to seek treatment from a healthcare team, which includes physicians and nurse specialists who are equipped to manage the complexity of the disease and its comorbidities. Importantly, therapy for PIDD can be self-administered at home, which has encouraged the transition toward a proactive stance that is at the heart of patient-centered chronic care management. We discuss the evolution of therapy, the issues with the disease, and challenges with its management within the framework of other chronic disease management programs. Suggestions and rationale to move case management of PIDD forward are presented with the intent that sharing our experiences will improve process and better manage outcomes in this patient population. The patient-centered model for the management of PIDD is applicable to the primary care settings, where nurse case managers assist patients through education, support them and their families, and facilitate access to community resources in an approach, which has been described as "guided care." The model also applies specifically to immunology centers where patients receive treatment or instruction on its self-administration at home. Patient-centered management of PIDD, with its emphasis on full involvement of patients in their treatment, has the potential to improve compliance with treatment, and thus patient outcomes, as well as patients' quality of life. The patient-centered model expands the traditional model of chronic disease management, which relies on evidence-based medicine, provider expertise, clinical information systems, and patient education. This approach supports patient self-management with strategies that empower and prepare them for their role as expert patients.

The Canadian Heart Health Strategy and Action Plan: Cardiac rehabilitation as an exemplar of chronic disease management

In October 2006, federal funding was announced for the development of a national strategy to fight cardiovascular disease (CVD) in Canada. The comprehensive, independent, stakeholder-driven Canadian Heart Health Strategy and Action Plan (CHHS-AP) was delivered to the Minister of Health on February 24, 2009. The mandate of CHHS-AP Theme Working Group (TWG) 6 was to identify the optimal chronic disease management model that incorporated timely access to rehabilitation services and end-of-life planning and care. The purpose of the present paper was to provide an overview of worldwide approaches to CVD and cardiac rehabilitation (CR) strategies and recommendations for CR care in Canada, within the context of the well-known Chronic Care Model (CCM). A separate paper will address end-of-life issues in CVD. TWG 6 was composed of content representatives, primary care representatives and patients. Input in the area of Aboriginal and indigenous cardiovascular health was obtained through individual expert consultation. Information germane to the present paper was gathered from international literature and best practice guidelines. The CCM principles were discussed and agreed on by all. Prioritization of recommendations and overall messaging was discussed and decided on within the entire TWG. The full TWG report was presented to the CHHS-AP Steering Committee and was used to inform the recommendations of the CHHS-AP. Specific actionable recommendations for CR are made in accordance with the key principles of the CCM. The present CR blueprint, as part of the CHHS-AP, will be a first step toward reducing the health care burden of CVD in Canada.

Pharmacists' Perspectives on Providing Chronic Disease Management Services in the Community — Part I: Current Practice Environment

Background: Several practice models have been developed to support pharmacists in providing chronic disease management. However, most of these models have not been readily accepted by pharmacists, which has led to low uptake and short-term change. Methods: Pharmacists were recruited to participate in focus groups held in Alberta and British Columbia. Qualitative methodologies involving a phenomenological approach with content analysis were used to gather and analyze information. Results: In total, 36 pharmacists participated in 8 focus groups. Analysis of their discussions revealed 4 main themes: the current practice environment and the need for education about, remuneration for and a plan for the implementation of chronic disease management services. Participants cited several challenges to the provision of this type of care, as experienced in the current practice environment: time constraints; relationships with physicians, patients and employers; limited access to clinical information; and absence of a model for chronic disease management in pharmacy practice. However, these perceptions were not universal, and pharmacists with experience in this area described some of these commonly cited “challenges” (e.g., relationships with physicians) as enablers in their own practices. In addition, staff pharmacists, regional managers and owners often had differing opinions about the key challenges and the role of remuneration. Conclusion: Some of the perceived challenges to providing chronic disease management described by staff pharmacists were not consistently supported by employers or those with experience in this practice area. This observation suggests that the greatest challenge to developing a successful model of chronic disease management for pharmacists lies in pharmacists' own perceptions about their relationships with other health care providers and their own role as health care professionals. These issues must be addressed if the practice of pharmacy is to move forward.

The TrueBlue study: Is practice nurse-led collaborative care effective in the management of depression for patients with heart disease or diabetes?

BackgroundIn the presence of type 2 diabetes (T2DM) or coronary heart disease (CHD), depression is under diagnosed and under treated despite being associated with worse clinical outcomes. Our earlier pilot study demonstrated that it was feasible, acceptable and affordable for practice nurses to extend their role to include screening for and monitoring of depression alongside biological and lifestyle risk factors. The current study will compare the clinical outcomes of our model of practice nurse-led collaborative care with usual care for patients with depression and T2DM or CHD.MethodsThis is a cluster-randomised intervention trial. Eighteen general practices from regional and metropolitan areas agreed to join this study, and were allocated randomly to an intervention or control group. We aim to recruit 50 patients with co-morbid depression and diabetes or heart disease from each of these practices. In the intervention group, practice nurses (PNs) will be trained for their enhanced roles in this nurse-led collaborative care study. Patients will be invited to attend a practice nurse consultation every 3 months prior to seeing their usual general practitioner. The PN will assess psychological, physiological and lifestyle parameters then work with the patient to set management goals. The outcome of this assessment will form the basis of a GP Management Plan document. In the control group, the patients will continue to receive their usual care for the first six months of the study before the PNs undergo the training and switch to the intervention protocol. The primary clinical outcome will be a reduction in the depression score. The study will also measure the impact on physiological measures, quality of life and on patient attitude to health care delivered by practice nurses.ConclusionThe strength of this programme is that it provides a sustainable model of chronic disease management with monitoring and self-management assistance for physiological, lifestyle and psychological risk factors for high-risk patients with co-morbid depression, diabetes or heart disease. The study will demonstrate whether nurse-led collaborative care achieves better outcomes than usual care.