Effective Chronic Disease Management Research Articles

CA8-02: Implementing a Community Health Initiative Using the Chronic Care Model

Background/AimsGroup Health, an integrated care system serving 600,000 members in Washington state, has developed a community health initiative (CHI) based on the medical home and the Chronic Care Model (expanded to emphasize community health promotion). Primary care providers want to maximize their limited time and resources for encouraging healthy behaviors but often are unaware of the full range of community services that can augment and support clinic-based care. The overall goal of the CHI is to improve health outcomes by integrating patient-centered approaches with community- based programs and services that promote better health.MethodsA CHI logic model was developed that defines expected short term (phase 1), intermediate and long term outcomes for its primary audience (patients and providers), for Group Health as an organization, and for health-promoting community resources and environments. The CHI strategy involves development of a searchable, web-based database that allows providers to easily refer patients to community-based programs that promote active living, healthful eating, and effective chronic disease management. Focus groups were held with providers to determine database scope and content and secondary data were analyzed and mapped to identify where the most vulnerable populations in Group Health?s service live.ResultsDuring phase 1 the database is being piloted at a Group Health clinic in a high needs area in King County, to test clinical-community linkage strategies and to set the stage for replication throughout Group Health, among safety net providers, and in the community at large. The pilot phase evaluation is primarily a process evaluation, assessing characteristics of the program that contribute to its success, the creation of linkages to community resources, participant satisfaction, recommendations for improvement, and fidelity of implementation.DiscussionThe interactive database shows promise as a tool for providers to engage patients in making healthy lifestyle choices and strengthening linkages between clinical practice and community resources. Piloting and evaluating the CHI will ensure the successful replication throughout Group Health, the safety net, and the broader community, and will contribute to the field by demonstrating successful linkages between primary care and community resources.

Ethnic differences in primary care management of diabetes and cardiovascular disease in people with serious mental illness

Patients with serious mental illness (SMI) have high rates of cardiovascular disease (CVD). In contrast to widespread perception, their access to effective chronic disease management is as high as for the general population. However, previous studies have not included analysis by ethnicity. To identify differences in CVD and diabetes management, by ethnicity, among people with SMI. Three inner east London primary care trusts with an ethnically diverse and socially deprived population. Data were obtained from 147 of 151 general practices. Coded demographic and clinical data were obtained from GP electronic health records using EMIS Web. The sample used was the GP registered population on diabetes or CVD registers (52,620); of these, 1223 also had SMI. The population prevalence of CVD and diabetes is 7.2%; this rises to 18% among those with SMI. People with SMI and CVD or diabetes were found to be as likely to achieve clinical targets as those without SMI. Blood pressure control was significantly better in people with SMI; however, they were more likely to smoke and have a body mass index above 30 kg/m(2). Ethnic differences in care were identified, with south Asian individuals achieving better cholesterol control and black African or Caribbean groups achieving poorer blood pressure control. Risk factor management for those with SMI shows better control of blood pressure and glycosylated haemoglobin than the general population. However, smoking and obesity rates remain high and should be the target of public health programmes. Ethnic differences in management mirror those in the general population. Ethnic monitoring for vulnerable groups provides evidence to support schemes to reduce health inequalities.

New models of care for psychology in Canada's health services.

Psychological services health care have expanded beyond traditional areas of mental health to the full spectrum of health disorders, as research has increasingly shown the importance of psychological processes health outcomes. Behavioural and psychological factors can contribute to the onset, course, or severity of many chronic diseases, and psychology has much to offer with clinically and cost-effective interventions. Good principles of care, involving appropriate assessment, evidence-based interventions, and close collaboration with other health care providers, are vital for effective chronic disease management, but can be difficult to realise given issues of timely access, patient volumes, and availability of psychological services publicly funded health care. This article provides an overview of psychological interventions diverse areas of health psychology, with examples of innovative Canadian clinical service delivery models, particularly focussing on integrated screening and treatment for cardiac patients, computerized delivery of insomnia treatment, screening and brief intervention prior to joint replacement surgery, and on-site psychological consultation for family physicians. The case examples, developed and implemented Winnipeg, Manitoba, demonstrate components for consideration when redesigning psychological service models, such as more systematic approaches to identifying patient needs, stepped levels of care that increase intensity of service relative to need, integration into systems already handling large patient volumes, innovative use of technology, and location of psychological resources in situ for timely, brief access. Although still early stages of development and evaluation, these models show promise for improved access and enhanced ability to deliver psychological service to relevant patient volumes. Keywords: psychology services, public health care, stepped interventions, online treatment The understanding of disease and the role of psychological processes has evolved recent decades with the explosion of research fields such as psychoneuroimmunology. The biopsychosocial model of illness has flourished as a more biomedically based model has failed to fully explain differences disease course and outcomes (Baum & Posluszny, 1999). In addition, health care services have been burdened by care related to chronic disease. That is, the discovery of antibiotics the early 20th century and improvements diet and living conditions have revolutionized treatment and prevention of infectious diseases and have led to a shin emphasis to chronic illness, rehabilitation, and quality of life (Ray, 2004; U.S. Department of Health and Human Services, 2000). There has been growing recognition of the major influence of behavioural and psychological factors the onset, course, and severity of many of the most common chronic diseases (Gonder-Frederick, Cox, & Ritterband, 2002; Graff et al., 2006; Kiecolt-Glaser, Mcguire, Robles, & Glaser, 2002; Yusef et al., 2004). As well, behavioural factors have been identified as the primary causes of half of all cancers resulting deaths developed countries (Adami, Day, Trichopoulos, & Willett, 2001; Colditz, DeJong, Hunter, Trichopoulos, & Willett, 1996). There is strong evidence that psychological interventions can improve symptoms and quality of life and decrease distress and health care utilization across a range of health conditions including heart disease, diabetes, arthritis, and chronic pain (Hunsley, 2002). Going one step further, prevention efforts based on lifestyle interventions for individuals with elevated disease risk have shown promise (Diabetes Prevention Program Research Group, 2002, 2009). Psychological services health care have expanded beyond traditional areas of mental health to the full spectrum of health disorders, as research has increasingly shown the importance of psychological processes health outcomes. …

Better and more efficient care through ICT-enabled integration of social care and healthcare services: experiences from two European projects

Unsynchronised social and health care service delivery leads to inefficiencies, duplication of resources and reduced levels of quality of care. Older people are particularly affected by this situation. They often need both types of services, such as support with daily living activities and chronic disease management. ICT has the potential to support integrated service delivery to achieve high quality independent living and wellbeing for older people across Europe and elsewhere. Against this background, the presentation will demonstrate experiences and results derived from the development and piloting of ICT-supported integrated care services in eight sites across Europe, namely Dublin, Hull, Milton Keynes, Malaga, Veldhoven, Geldrop, Eindhoven and Bielefeld. Through innovative usage of ICT, current ‘silos’ in service delivery are broken up to allow for cooperation across relevant care sectors and participation of family members. The integrated services are to support the effective management of chronic diseases, and to address issues which affect independence, such as reduced agility, vision or hearing, in order to significantly improve the quality of life for older people and their carers. A dedicated programme of service process innovation complemented by adaptation of technology is being pursued in order to develop an integrated digital support infrastructure and related services:

의사들의 유헬스케어 서비스에 대한 인식과 사용의도

Although u-healthcare service is emerged as an alternative method for effective chronic disease management services, the service has not yet been applied for real healthcare setting. The objective of this study is to explore the doctors` perception and influential factors on intention to use u-healthcare service. We conducted survey for physicians about u-healthcare service provision to compare characteristics by different groups. In addition, logistic regression analysis is conducted to find out factors affecting the usage intention. As a result, doctors responded only 16.0% of total respondents had experience of u-healthcare services, but also showed that as high as 70.1% had intention to use service. Also, respondents answered that u-healthcare services is appropriate to apply for chronic disease prevention and diabetes and hypertension are suggested as the most appropriate diseases in order. The intention to use the u-healthcare service by non-university hospital doctors was 3.7 times higher than university hospital doctor. This study shows that identifying the differences of doctors` awareness and also the intention to use about the u-healthcare services will contribute to develop more effective business model.

NPs and the Management of Chronic Disease

Marilyn W. Edmunds PhD, NP D uring discussions and in articles written about recent health care reform, nurse practitioners (NPs) stressed the strengths of the services they provide to patients. This was an important time to emphasize that NPs enjoy being NPs and see ourselves first and foremost as nurses—we just have greater skills and knowledge and more legitimacy in working with patients to do many of the important things that we have always done as nurses—teaching, counseling, and advocacy. But the thing that caught the attention of many legislators was the fact that one of the most important services we provide to patients is care coordination, especially those patients with chronic diseases who may be seeing several specialists. I remember when I was a novice NP and was told, “NPs manage minor acute problems and stable chronic disease,” leaving physicians to care for the patients who had multiple problems and significant health challenges. It did not take me long to recognize that the patients who got shifted to my caseload were often the sickest, elderly patients with numerous chronic diseases, multiple medications, and few resources to help them cope with their family, social, and economic problems. They were often not the patients with stable chronic disease but those who required providers with careful listening skills who would do repetitive teaching and provide intense management of their many illnesses. The medical residents who changed clinic assignments every 2 months couldn’t and didn’t get involved in the problems of these patients, so the sickest, most unstable, and most challenging patients often were in the portfolio of the clinic NPs. I learned early that management of chronic disease is an art form. Our health care colleagues have grown to recognize the increasing contributions of NPs in helping patients deal with chronic disease. Talented NPs enjoy the special relationship that nurses have always had with patients. NPs who incorporate the care integration so essential to nursing into the medical cure dimension continue to practice as NPs and not as physicians or their assistants. NPs should always excel in this dimension of care. This type of nursing behavior must not be lost as students acquire other skills in their new NP role. Management of chronic disease requires patient cooperation, their full participation, and eventually development of self-management skills. How NPs help patients learn to help themselves is an important long-term care objective. The Agency for Healthcare Research and Quality (AHRQ) has recognized the importance of management of chronic disease and over time has established a Health Care Innovations Exchange program to provide tools that NPs can use to help patients learn to manage their own health. The AHRQ’s Web site (www.ahrq.gov) features a variety of innovative programs that provide rich resources to the NP and patient who are working together for more effective chronic disease management.

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 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.

Accurate monitoring leads to effective control and greater learning of patient education materials.

Effective management of chronic diseases (e.g., diabetes) can depend on the extent to which patients can learn and remember disease-relevant information. In two experiments, we explored a technique motivated by theories of self-regulated learning for improving people's learning of information relevant to managing a chronic disease. Materials were passages from patient education booklets on diabetes from NIDDK. Session 1 included an initial study trial, Session 2 included self-regulated restudy, and Session 3 included a final memory test. The key manipulation concerned the kind of support provided for self-regulated learning during Session 2. In Experiment 1, participants either were prompted to self-test and then evaluate their learning before selecting passages to restudy, were shown the prompt questions but did not overtly self-test or evaluate learning prior to selecting passages, or were not shown any prompts and were simply given the menu for selecting passages to restudy. Participants who self-tested and evaluated learning during Session 2 had a small but significant advantage over the other groups on the final test. Secondary analyses provided evidence that the performance advantage may have been modest because of inaccurate monitoring. Experiment 2 included a group who also self-tested but who evaluated their learning using idea-unit judgments (i.e., by checking their responses against a list of key ideas from the correct response). Participants who self-tested and made idea-unit judgments exhibited a sizable advantage on final test performance. Secondary analyses indicated that the performance advantage was attributable in part to more accurate monitoring and more effective self-regulated learning. An important practical implication is that learning of patient education materials can be enhanced by including appropriate support for learners' self-regulatory processes.

Evaluation of chronic disease self-management programme (CDSMP) for older adults in Hong Kong.

To evaluate the locally-adapted CDSMP for older adults with chronic diseases in Hong Kong in the primary care setting. A longitudinal, quasi-experimental study. Community-based and primary care setting. Seven hundred and seventy-two participants aged 55 or above with at least one chronic disease and were living in the community. The 6-weeks programme consisted of 6 group sessions, with each session lasting for 2.5 hours. Trained professional and elder lay leaders facilitated participants to gain essential self-management knowledge and skills for the effective management of chronic diseases. At baseline and 6 months, four categories of outcome measures were documented, covering self-management behaviours, self-efficacy, health status, and health care utilization. 302 and 298 participants in the intervention and control groups completed 6 months follow-up respectively. Participants in the intervention group reported significant improvements in all self-management behaviours and self-efficacy measures, and 5 health status measures (social role limitation, depressive symptoms, health distress, symptoms of pain and discomfort, and self-rated health) when compared with those in the control group. The locally-adapted CDSMP may improve self-management behaviours, self-efficacy and health status among older adults with chronic diseases in Hong Kong. CDSMP may be integrated into primary care services for older adults.

Management of long-term conditions in a prison setting

This article, the fourth in a five-part series, explores the management of long-term conditions in the prison population, as well as patient-centred approaches to care and the challenges this may present. It discusses the effective management of chronic diseases and the importance of evidence-based practice in improving offender health care. The need for an understanding of the sociological and psychological perspectives of living with a long-term condition is explained.

Pulmonary rehabilitation: today and tomorrow

Educational aims To review the rationale for and the components of comprehensive pulmonary rehabilitation. To evaluate the role of pulmonary rehabilitation in chronic obstructive pulmonary disease exacerbation. To discuss the potential role of pulmonary rehabilitation in the critically ill patient and the patient with lung cancer Summary Comprehensive and effective clinical management of chronic obstructive pulmonary disease (COPD) requires an interdisciplinary, integrated care approach that includes both pharmacological and nonpharmacological therapies. Pulmonary rehabilitation is a nonpharmacological, interdisciplinary, patient-centred intervention that is a crucial component of the optimal care for patients with COPD, and, as such, has a prominent place in all current guidelines for the treatment of this disease [1–3]. This article will begin by outlining the components of pulmonary rehabilitation and the rationale behind its effectiveness. It will then focus on some emerging areas of clinical and research interest which will illustrate how the principles of pulmonary rehabilitation can be adapted to nontraditional areas to improve patient outcomes. These include COPD exacerbations, lung cancer and critical illness.

Preparing nurses for primary health care futures: how well do Australian nursing courses perform?

Health reform is increasingly targeted towards strengthening and expansion of primary health systems as care is shifted from hospitals to communities. The renewed emphasis on prevention and health promotion is intended to curb the tide of chronic disease and sustain effective chronic disease management, as well as address health inequities and increase affordable access to services. Given the scope of nurses' practice, the success of Australia's health system reforms are dependent on a nursing workforce that is appropriately educated and prepared for practice in community settings. This article reports on the results of an Australian national audit of all undergraduate nursing curricula to examine the extent of professional socialisation and educational preparation of nurses for primary health care. The results of the audit are compared with Australian nursing standards associated with competency in primary health care. The findings indicate that Australian nursing competencies are general in their approach to skills and knowledge, not specifying any particular competencies for primary health care, while undergraduate student preparation for practice in primary health and community settings is patchy and not keeping pace with reform agendas that promote expanded roles for nurses in primary health care, prevention and health promotion. The implication for nursing curriculum reform is that attention to achieving nursing graduate capacity for primary health care and health promotion is a priority.

Patients, persons or partners? Involving those with chronic disease in their care

Self-care management is essential for effective chronic disease management. Yet prevailing approaches of healthcare practitioners often undermine the efforts of those who require on-going medical attention for chronic conditions, emphasizing their status as patients, failing to consider their larger life experience as people, and most importantly, failing to consider them as people with the potential to be partners in their care. This article explores two approaches for professional-patient interaction in chronic disease management, namely, patient-centred care and empowering partnering, illuminating how professionals might better interact with chronically ill individuals who seek their care. The opportunities, challenges, theory and research evidence associated with each approach are explored. The advantages of moving beyond patient-centred care to the empowering partnering approach are elaborated. For people with chronic disease, having the opportunity to engage in the social construction of their own health as a resource for everyday living, the opportunity to experience interdependence rather than dependence/independence throughout on-going healthcare, and the opportunity to optimize their potential for self-care management of chronic disease are important justifications for being involved in an empowering partnering approach to their chronic disease management.

Does Access to Care Still Affect Health Care Utilization by Immigrants? Testing of an Empirical Explanatory Model of Health Care Utilization by Korean American Immigrants with High Blood Pressure

Despite well-known benefits of health care utilization for the effective management of chronic diseases, the underlying mechanism of understanding health care utilization in ethnic minority population has not been systematically explored. The purpose of this paper is to examine the predictive ability of a health care utilization model by analyzing the interplay between predisposing, enabling, and need factors. The sample consisted of hypertensive Korean American immigrants (KAIs) 40-64 years of age who participated in a self-help intervention for high blood pressure care (SHIP-HBP). Using structured questionnaires, data were collected from 445 KAIs at baseline and analyzed with path analysis. Insurance status and relevant medical history were not just strong direct effects but also carried the most total effect on the health care utilization of these patients. Life priorities, years of residence in the US and perceived income level exerted indirect effects through the participants' insurance status. Our statistical analysis indicated a good fit for the proposed model (x (2) = 28.4, P = 0.29; NFI = 0.91; CFI = 0.99; RMSEA = 0.02). Overall, the model explained 18% of the variance in health care utilization of hypertensive KAIs. These findings strongly support a need to improve access to health care for KAIs by introducing a variety of community resources and building sustainable community infrastructures.

Changing Healthcare: Stakeholder Perceptions of the Burden of Chronic Disease and the Value of Teams, Measurements and Communication

Canadian healthcare is changing. Over the course of the past decade, the Health Care in Canada Survey (HCIC) has annually measured the reactions of the public and professional stakeholders to many of these change forces. In HCIC 2008, for the first time, the public's perception of their health status and all stakeholders' views of the burden and effective management of chronic diseases were sought. Overall, Canadians perceive themselves as healthy, with 84% of adults reporting good-to-excellent health. However, good health decreased with age as the occurrence of chronic illness rose, from 12% in the age group 18-24 to 65% for the population =65 years. More than 70% of all stakeholders were strongly or somewhat supportive of the implementation of coordinated care, or disease management programs, to improve the care of patients with chronic illnesses. Concordant support was also expressed for key disease management components, including coordinated interventions to improve home, community and self-care; increased wellness promotion; and increased use of clinical measurements and feedback to all stakeholders. However, there were also important areas of non-concordance. For example, the public and doctors consistently expressed less support than other stakeholders for the value of team care, including the use of non-physician professionals to provide patient care; increased patient involvement in decision-making; and the use of electronic health records to facilitate communication. The actual participation in disease management programs averaged 34% for professionals and 25% for the public. We conclude that chronic diseases are common, age-related and burdensome in Canada. Disease management or coordinated intervention often delivered by teams is also relatively common, despite its less-than-universal acceptance by all stakeholders. Further insights are needed, particularly into the variable perceptions of the value and efficacy of team-delivered healthcare and its important components.

Healthcare experiences of the homeless

To explore the healthcare experiences of homeless individuals and inform providers of the barriers created by the situation of homelessness. This was a qualitative research study using a grounded theory approach. The sample included homeless individuals older than 18 years living in northeastern Wisconsin. This research provided rich insight into the healthcare experiences of the homeless. Five key conclusions were made: (a) the great majority of homeless people have an external locus of control; (b) most homeless individuals lack the necessary resources to meet their physical needs of shelter, air, water, and food; (c) most homeless individuals lack the financial resources to seek adequate health care; (d) access to resources is limited because of poor transportation, telephones, and mail; and (e) all those interviewed felt that healthcare providers lack compassion for the homeless. Healthcare providers can use the concepts discovered in this study to help improve their skills and comfort level when working with homeless individuals. A decrease in acute illnesses and an increase in the effective management of chronic disease resulting in fewer long-term complications and medical costs because of these unnecessary complications could be seen. Healthcare professionals may also volunteer to become more involved with the care of the homeless if they are confident in their skills. Improving the health of the homeless in the community will result in improvements in the overall health of the community.

Managing chronic illness in Europe: a comparative analysis

Many countries are experimenting with new models of care delivery involving enhanced integration and coordination of services to better meet the needs of those living with chronic illness. However, the available evidence on the relative value of different forms of integration remains uncertain. This paper will present the findings of a study undertaken in close collaboration with and co-funded by the European Observatory on Health Systems and Policies. It will provide an overview of strategies to chronic disease management that have been developed andyor implemented in five European countries (Denmark, England, France, Germany, Sweden) and Australia. It will also assess some of the contextual factors that enable or hinder implementation of strategies to address chronic illness. It illustrates the immense diversity among European countries in their approaches to address the rising burden of chronic disease. Approaches not only vary between but also within countries, and reflect to considerable degree the general approaches of health care financing and organisation taken. Thus, in many countries where strong primary care teams exist there has been a progressive shift in the management of many chronic diseases to nurse-led clinics in primary care, for example in England, Sweden and the Netherlands. The involvement of the non-medical profession in France or Germany is low, partly because of legal and professional restrictions on the deployment of nurses outside hospital. Instead, Germany has introduced dedicated disease management programmes which patients and providers can join voluntarily, while France is incentivising the formation of provider networks so as to improve coordination and multidisciplinary working along the continuum of care. The role of patient self-management is being acknowledged as a key component of effective chronic disease management in many countries; yet, systems that support self-management systematically remain relatively weak in many settings. The sustainability of chronic care models faces considerable challenges in all health care settings. These include administrative and financial obstacles to enhance the coordination andyor integration of health and socialycommunity care services; underymis-investment in suitable information systems; conflicting policies (e.g. pursuing activity-based funding vs. aiming to shift care into the community); a focus on cost reduction; and the potential impact of electoral cycles. An effective response to the rising burden of chronic disease requires a health system environment that allows for the development and implementation of structured approaches to chronic disease management. Experience suggests that systems that are characterised by fragmentation of health services are facing considerable challenges in the successful implementation of system-wide strategies to provide care for patients with chronic illness.

Health Care as If Health Mattered

THERE IS CONSENSUS ABOUT THE NEED FOR FUNDAMENtal change in the US health care system and there has beenattentiontotheimportantproblemsofinadequate access and increasing costs. But the most serious shortcoming—that the nation’s health system is not designed to maximize health—has been overshadowed. Individuals in theUnitedStatesreceiveonlyabouthalftherecommendedmedical services. Only 43% of individuals with diagnosed diabetes, 37% with hypertension, and 25% with hypercholesterolemia have adequate control of their disease; furthermore, less than20%ofsmokerswhotrytoquitreceiveassistancefrom theirphysicians,andonly2%areprescribedpharmacotherapy. Lack of effective primary health care is a public health problem that results in avoidable blindness, amputations, strokes, heart attacks, and premature death. Nearly 9 of 10 Americans with uncontrolled diabetes, hypertension, and hypercholesterolemia already have private or public health insurance. If reforming US health care results only in expanded access to care, costs will increase faster but with limited health benefits. If only cost controls are instituted, even more individuals will be denied access to needed care. Health care must be restructured to make maximizing health the organizing principle. To do this, 3 synergistic changes are needed: (1) payment that offers substantial rewards for disease prevention and effective management of chronic disease; (2) an information system oriented toward prevention; and (3) changes in care management and practice workflows. Efforts to implement each of these changes separately have failed to substantially improve care because they lacked sufficient focus on prevention and because these 3 interventions are needed jointly. Pay-for-performance initiatives have been hamperedby lackof reliable informationonqualityofcareand outcomes. Electronic health records (EHRs) have had limited or no effect because most have not been designed to facilitate, encourage, and trackpreventive services for entirepatientpopulations.Andwithoutfinancial incentivesorthepower of EHRs to track individual patients and patient panels, clinicians are not able to achieve scale or sustain improvements in preventive services or care for those with chronic conditions. Inmostof thecurrentUShealthcare system, treating illness is more profitable than promoting health. Preventive services are usually poorly reimbursed or not reimbursed at all. A patient who has sustained a myocardial infarction may require cardiac surgery that costs $100 000 or more. But a physician who counsels patients to adopt a healthy lifestyle, prescribes the right medications, and follows up regularly to help reduce the patient’s infarction risk can lose money. As a result, health care information systems and practice workflows do not prioritizepreventionor facilitatemanagementofchronicdisease. If a substantialproportionofphysicians’ reimbursementswere based on the proportion of patients who complete all vaccinations and core cancer screenings, have good management of bloodpressureandcholesterol levels, andeitherdonot smoke or have documented assisted attempts at quitting, many more patients would receive these lifesaving preventive services. Todate,pay-for-performancesystemshavegeneratedscant evidence of measurable quality improvements and may offernoadvantageoverfee-for-service inimprovingcareandcontainingcosts. Pay-for-performancesystemsdonotfundamentallyalter thesubstantial financialadvantagesof intensivetreatmentofadvanced illnessoverdiseaseprevention.Currentpayfor-performanceprogramsofferonlysmallperformancebonuses, are often not integrated with quality-improvement initiatives, and often focus on what is easy to measure rather than what willmost improve thehealthofpatients andcommunities. Of thehundredsofambulatorycaremeasuresapprovedbynational quality organizations, none address screening the generalpopulationforhumanimmunodeficiencyvirus,hypercholesterolemia, or depression. Furthermore, these measures often are based on processes performed, such as whether physiciansmeasure lipid levels, rather thanonoutcomes, such as how well lipid levels are controlled. But processes and outcomes may not be correlated. Pay-for-performance might be much more effective at improving health, and would encourage innovation in doing so, if it rewarded outcomes or reliable predictors of outcomes such as control of blood pressure and cholesterol levels and if the rewards were prioritized based on their potential to increase patients’ years of healthy life. Well-designedandeffectively implementedEHRsareanecessary,butnotsufficient,component tochangepaymentstructure and improve health care system performance. EHRs have thepotential toenablevalidclinicalqualitymeasurement,highqualitypreventivecare,andbettermanagementofchronicconditions such as hypertension and hypercholesterolemia. The US Department of Veterans Affairs (VA), which has a financial incentive to improve prevention, implemented an effective EHR system in the mid-1990s and now outperforms the private sector on almost every measure of quality. Patients at VA facilities receive 67% of the recommended level of health care vs 51% received by non-VA patients. A systematic review found that in a small number of institutions, EHRs have

Senator Christopher Dodd’s Health Plan

Our health care system is plagued by four overriding deficiencies: lack of universal coverage, high costs, inadequate chronic illness prevention and management, and deficient public health preparedness. An inadequate information technology infrastructure and suboptimal quality of care are aspects of one or more of these four challenges. As a result of these shortcomings, the American people are actually less healthy than our counterparts in developed nations around the world. This travesty saps our potential as individuals and as a country. Lost productivity associated with having 47 million uninsured people costs up to $205 billion per year. Accordingly, I have proposed a comprehensive plan for health care reform marked by its inclusiveness and balance. PUTTING UNIVERSAL COVERAGE FIRST Universal coverage forms the predicate of solving many of our health system problems. Without the continuity of access universal coverage promotes, effective chronic disease management that improves health outcomes and generates savings will be much harder to attain. Certainly, disaster preparedness becomes dramatically more difficult while large pockets of uncompensated care and reliance on hospital emergency rooms remain significant characteristics of American health care. My health care plan provides for unequivocal universal health care coverage through universal responsibility. Americans will be able to get their private insurance through a health insurance marketplace called Universal HealthMart. Modeled after the Federal Employees Health Benefits Plan, Universal HealthMart will provide Americans with the same benefits as every Member of Congress. Insurance company discrimination based on condition will be ended. Every employer and individual will be given the chance to go to Universal HealthMart to purchase high-quality, affordable health care or, if they wish, keep their existing insurance arrangements. If a person is unable to pay for insurance or cover the entire cost, their costs will be subsidized on a sliding scale based on income. Business contributions will also be based on ability to pay. Every American with an income below 100 percent of the Federal Poverty Level will become eligible for Medicaid while changes in the federal match will assure that states are held harmless for this expansion. My plan is the only plan to provide for automatic enrollment and a defined timeline to implement universal coverage. Coverage will occur through direct enrollment as people choose their plans or automatically when people file their tax returns, complete W-4's, or show up for health care with a provider. Through the process of automatic coverage and enrollment, universal coverage is guaranteed. Within 2 years of enactment, all children, young adults to age 29, and adults age 55-64 will be covered. Over the next two years, all remaining adults between 30-54 will be enrolled. MAKING HEALTH CARE MORE AFFORDABLE My plan will make healthcare more affordable because health insurance premiums will be based on ability to pay. In addition, my health care plan will reduce costs throughout the system, especially administrative costs. First, as more and more Americans participate in the marketplace, the agency contracting with health plans on their behalf gains increasing leverage to require sensible efficiencies and price accountability. Second, according to McKinsey Global Institute, medical underwriting and marketing costs alone account for $64 billion in excess insurance company expenses. My plan eliminates insurance company discrimination based on condition, while marketing will be consolidated and streamlined. It explicitly redirects premium dollars to prevention and management of chronic illness, the effects of which are discussed more fully below. IMPROVING CHRONIC ILLNESS MANAGEMENT Chronic illness accounts for 74 percent of private health insurance medical spending and 96 percent of Medicare spending. …