Chronic care management
Encyclopedia
Chronic care management encompasses the oversight and education activities conducted by health care professionals
to help patients with chronic diseases and health conditions such as diabetes, high blood pressure, lupus
, multiple sclerosis
and sleep apnea
learn to understand their condition and live successfully with it. This term is equivalent to disease management (health)
for chronic conditions. The work involves motivating patients to persist in necessary therapies and interventions and helping them to achieve an ongoing, reasonable quality of life.
Effective medical care usually requires longer visits to the doctor's office than is common in acute care. Moreover, in treating chronic illnesses, the same intervention, whether medical or behavioral, may differ in effectiveness depending on when in the course of the illness the intervention is suggested. Fragmentation of care is a risk for patients with chronic diseases, because frequently multiple chronic diseases coexist. Necessary interventions can require input from multiple specialists that may not usually work together, and to be effective, they require close, careful coordination.
As a consequence, patients with chronic conditions can fare poorly in the current acute-care model of care delivery.
(ODLs). Resulting information may inform both self care and clinical care.
It would appear from the above, that chronically ill persons are better cared for by primary care physicians. Considering the diverse nature of chronic health problems and the roles that psychosocial environments play in their course, a purely biological model of care is usually inadequate. The biopsychosocial model of care is the ideal alternative.
Nurse researchers, such as S. Wellard, C. S. Burckhardt, C. Baker and P. N. Stern, and I. M. Lubkin and P. D. Larson, were often on the front lines of actual care for patients with ongoing treatments for conditions such as diabetes or renal failure. They stated that their patients experienced a trajectory of "phases," and that during some of these phases the patients responded quite differently to the same interventions.
Individuals who suffered from chronic illnesses, such as C. Register and S. Wells, have given detailed accounts of their experiences and made recommendations about how to manage chronic conditions. Associations proliferated for those with specific conditions (Sjögren's syndrome
, chronic fatigue syndrome
, peripheral neuropathy
, etc.), and these groups have engaged in advocacy work, acted as clearinghouses for information, and began funding research.
Edward H. Wagner, M.D., Director of The MacColl Institute for Healthcare Innovation, Director of The Robert Wood Johnson Foundation national program "Improving Chronic Illness Care", and Senior Investigator at Group Health Research Institute in Seattle, WA developed the Chronic Care Model, or CCM. The CCM summarizes the basic elements for improving care in health systems on different levels. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. The Chronic Care Model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.
The Stanford Self-Management Program is a community-based self-management program that helps people with chronic illness gain self-confidence in their ability to control their symptoms and manage how their health problems will affect their lives.
Partnership for Solutions, a Johns Hopkins/Robert Wood Johnson collaborative, conducts research to improve the care and quality of life for individuals with chronic health conditions.
J. O. Prochaska and his colleagues, investigating issues associated with the treatment of addictions, have described a transtheoretical model
of behavior change as a process rather than an event. They have advocated assessment and treatment based on the patient’s stage in the process.
Patricia Fennell
, working on the experiences of imposed change (such as illness, grief, or trauma), has developed the Fennell Four Phase Model of chronic illness. Fennell says people commonly experience four phases as they learn to incorporate their changed physical abilities or psychological outlook into their personality and lifestyle: Crisis, Stabilization, Integration, and Resolution.
Health care provider
A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....
to help patients with chronic diseases and health conditions such as diabetes, high blood pressure, lupus
Lupus erythematosus
Lupus erythematosus is a category for a collection of diseases with similar underlying problems with immunity . Symptoms of these diseases can affect many different body systems, including joints, skin, kidneys, blood cells, heart, and lungs...
, multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...
and sleep apnea
Sleep apnea
Sleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
learn to understand their condition and live successfully with it. This term is equivalent to disease management (health)
Disease management (health)
Disease management is defined as "a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant." For people who can access health care practitioners or peer support it is the process whereby persons with...
for chronic conditions. The work involves motivating patients to persist in necessary therapies and interventions and helping them to achieve an ongoing, reasonable quality of life.
Chronic Care and the Medical System
Historically, there has been little coordination across the multiple settings, providers and treatments of chronic illness care. In addition, the treatments for chronic diseases are often complicated, making it difficult for patients to comply with treatment protocols.Effective medical care usually requires longer visits to the doctor's office than is common in acute care. Moreover, in treating chronic illnesses, the same intervention, whether medical or behavioral, may differ in effectiveness depending on when in the course of the illness the intervention is suggested. Fragmentation of care is a risk for patients with chronic diseases, because frequently multiple chronic diseases coexist. Necessary interventions can require input from multiple specialists that may not usually work together, and to be effective, they require close, careful coordination.
As a consequence, patients with chronic conditions can fare poorly in the current acute-care model of care delivery.
Personal Chronic Care Management
Patients with chronic conditions have an important role in the management of their conditions, as they are often the ones administering the treatments in everyday life. They also play an important role in monitoring their health and changes in their health by means of Observations of Daily LivingObservations of Daily Living
Observations of Daily Living are cues that people attend to in the course of their everyday life, that inform them about their health.ODLs are different from signs, symptoms, and clinical indicators in that they are defined by the patient, and are not necessarily directly mapped to biomedical...
(ODLs). Resulting information may inform both self care and clinical care.
Importance of Chronic Care Management
Certain problems related to chronic illness are not specifically medical, but involve patients' interactions with families and workplaces. Interventions often require patients and families to make difficult lifestyle changes. Patients need to be educated on the benefits of treatment and the risks of not properly following their treatment regimen. They need to be motivated to comply because treatment usually produces an improved state, rather than the results that most patients desire—a cure. Chronic care management helps patients systematically monitor their progress and coordinate with experts to identify and solve any problems they encounter in their treatment.It would appear from the above, that chronically ill persons are better cared for by primary care physicians. Considering the diverse nature of chronic health problems and the roles that psychosocial environments play in their course, a purely biological model of care is usually inadequate. The biopsychosocial model of care is the ideal alternative.
History of Chronic Care Management
Although acute care has characterized all medical care until recently, several varieties of managed care have emerged in the past decades in an effort to improve care, reduce unnecessary service utilization and control spiraling costs. Despite its initial promise, however, managed care has not achieved truly coordinated care. In actual operation it appears to emphasize its fiscal goals. Moreover, managed care does not address the complexity of chronic conditions, and in the interests of cost-cutting, tends to reduce time with patients rather than increase it.Chronic Care Models
In the latter part of the 20th century, researchers began to develop care models for the assessment and treatment of the chronically ill.Nurse researchers, such as S. Wellard, C. S. Burckhardt, C. Baker and P. N. Stern, and I. M. Lubkin and P. D. Larson, were often on the front lines of actual care for patients with ongoing treatments for conditions such as diabetes or renal failure. They stated that their patients experienced a trajectory of "phases," and that during some of these phases the patients responded quite differently to the same interventions.
Individuals who suffered from chronic illnesses, such as C. Register and S. Wells, have given detailed accounts of their experiences and made recommendations about how to manage chronic conditions. Associations proliferated for those with specific conditions (Sjögren's syndrome
Sjögren's syndrome
Sjögren's syndrome , also known as "Mikulicz disease" and "Sicca syndrome", is a systemic autoimmune disease in which immune cells attack and destroy the exocrine glands that produce tears and saliva....
, chronic fatigue syndrome
Chronic fatigue syndrome
Chronic fatigue syndrome is the most common name used to designate a significantly debilitating medical disorder or group of disorders generally defined by persistent fatigue accompanied by other specific symptoms for a minimum of six months, not due to ongoing exertion, not substantially...
, peripheral neuropathy
Peripheral neuropathy
Peripheral neuropathy is the term for damage to nerves of the peripheral nervous system, which may be caused either by diseases of or trauma to the nerve or the side-effects of systemic illness....
, etc.), and these groups have engaged in advocacy work, acted as clearinghouses for information, and began funding research.
Edward H. Wagner, M.D., Director of The MacColl Institute for Healthcare Innovation, Director of The Robert Wood Johnson Foundation national program "Improving Chronic Illness Care", and Senior Investigator at Group Health Research Institute in Seattle, WA developed the Chronic Care Model, or CCM. The CCM summarizes the basic elements for improving care in health systems on different levels. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. The Chronic Care Model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.
The Stanford Self-Management Program is a community-based self-management program that helps people with chronic illness gain self-confidence in their ability to control their symptoms and manage how their health problems will affect their lives.
Partnership for Solutions, a Johns Hopkins/Robert Wood Johnson collaborative, conducts research to improve the care and quality of life for individuals with chronic health conditions.
J. O. Prochaska and his colleagues, investigating issues associated with the treatment of addictions, have described a transtheoretical model
Transtheoretical Model
The Transtheoretical Model of Behavior Change assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to action and maintenance....
of behavior change as a process rather than an event. They have advocated assessment and treatment based on the patient’s stage in the process.
Patricia Fennell
Patricia Fennell
Patricia A. Fennell created the Fennell Four Phase Model for understanding and treating chronic medical and mental health conditions, trauma, and the effects of crime. Jeffrey Turner, in his book American Families in Crisis: A Reference Handbook, considers her a nationally recognized expert in the...
, working on the experiences of imposed change (such as illness, grief, or trauma), has developed the Fennell Four Phase Model of chronic illness. Fennell says people commonly experience four phases as they learn to incorporate their changed physical abilities or psychological outlook into their personality and lifestyle: Crisis, Stabilization, Integration, and Resolution.
See also
- Chronic careChronic careChronic care refers to medical care which addresses preexisting or long term illness, as opposed to acute care which is concerned with short term or severe illness of brief duration. Chronic medical conditions include, but are not limited to, asthma, emphysema, chronic bronchitis, congestive heart...
- DMAA: The Care Continuum AllianceDMAA: The Care Continuum AllianceThe Care Continuum Alliance is an industry trade group of corporations and individuals that "promotes the role of population health improvement in raising the quality of care, improving health outcomes and reducing preventable health care costs for individuals with chronic conditions and those at...
- Medical homeMedical homeThe medical home, also known as the patient-centered medical home , is defined as "a health care setting that facilitates partnerships between individual patients, and their personal providers, and when appropriate, the patient’s family". It is "an approach to providing comprehensive primary care...
- Non-communicable diseaseNon-communicable diseaseA non-communicable disease, or NCD, is a medical condition or disease which is non-infectious. NCDs are diseases of long duration and generally slow progression. They include heart disease, stroke, cancer, asthma, diabetes, chronic kidney disease, osteoporosis, Alzheimer's disease, cataracts, and...
s
Further Reading
- Packer, T., Simpson, C., Drury, V., Sim, S., Pereira, M., Re, M. (2008). Living Safe - a self-management program for people with vision impairment. Perth, WA: Curtin University.
- Packer, T., Drury, V., Ghahari, S., & Doorey, J. (2008). Self-management support. An introduction for health professionals. Perth: Curtin University of Technology.