Chronic care management

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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, systemic lupus erythematosus, multiple sclerosis, and sleep apnea learn to understand their condition and live successfully with it. This term is equivalent to disease management 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.

Contents

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, a phenomenon known as multimorbidity. Necessary interventions can require input from multiple specialists that may not usually work together, and to be effective, they require close, careful coordination. Research has shown that highly fragmented care for Medicare beneficiaries with multiple chronic conditions are more likely to present in emergency rooms and be admitted than others. [1]

As a consequence, patients with chronic conditions can fare poorly in the current acute-care model of care delivery.

Historically, reimbursement has been challenging for care coordination services. Medicare recently started paying for services related to chronic care management. Medicare pays a monthly fee for patients who consent to treatment for a minimum of 20 minutes of telehealth services. [2]

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 Living (ODLs). [3] Resulting information may inform both self care and clinical care.

Importance

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. A study across multiple healthcare organizations has shown promising results through embracing the role of community health workers to assist vulnerable populations improve chronic disease management and care. [4] This addition to the care team can further supplement a biopsychosocial model of care as an alternative.

History

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. [5]

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, [6] C. S. Burckhardt, [7] C. Baker and P. N. Stern, [8] and I. M. Lubkin and P. D. Larson, [9] were often on the front lines of actual care for patients with ongoing treatments for conditions such as diabetes or kidney failure. They stated that their patients experienced a series of "phases", and that during some of these phases the patients responded to the same interventions quite differently.

Individuals who had chronic illnesses, such as C. Register [10] and S. Wells, [11] 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, MD, MPH, Director Emeritus of The MacColl Institute for Healthcare Innovation, and former Director of The Robert Wood Johnson Foundation national program "Improving Chronic Illness Care", and Emeritus Investigator at Kaiser Permanente Washington Health Research Institute in Seattle, WA (formerly Group Health Research Institute) 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. [12]

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. [13]

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. [14]

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. [15]

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. [16] [17]

Established by the investment banking firm Wyatt Matas, the term Care Cycle Management is a chronic care business model that integrates interventional disease management with care delivery to manage the care of high-cost patients. [18]

The Flinders Human Behaviour & Health Research Unit (based in Adelaide, South Australia) has developed the Flinders ProgramTM, a generic set of tools and processes that allows for assessment of chronic condition management behaviours, collaborative identification of problems and goal setting leading to the development of individualised care plans with the goal of raising the quality of life for people living with chronic disease. The Flinders ProgramTM has been adapted to specific contexts to meet the needs of Indigenous Australians and veterans. [19] [20]

Chronic care models such as the delivery of chronic disease management programs may be effective for patients with long-term chronic conditions. For patients with asthma, having a coordinated program involving multiple health care professionals can make improvements in aspects such as patients perceived quality of life, lung functioning and the severity of their asthma. [21]

A range of studies have shown mindfulness-based pain management (MBPM) to be beneficial for those with chronic pain and other long-term conditions. [22] [23] [24]

See also

Related Research Articles

Chronic pain or chronic pain syndrome is a type of pain that is also known by other titles such as gradual burning pain, electrical pain, throbbing pain, and nauseating pain. This type of pain is sometimes confused with acute pain and can last from three months to several years; various diagnostic manuals such as DSM-5 and ICD-11 have proposed several definitions of chronic pain, but the accepted definition is that it is "pain that lasts longer than the expected period of recovery."

Palliative care is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses. Within the published literature, many definitions of palliative care exist. The World Health Organization (WHO) describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain, illnesses including other problems whether physical, psychosocial, and spiritual". In the past, palliative care was a disease specific approach, but today the WHO takes a broader patient-centered approach that suggests that the principles of palliative care should be applied as early as possible to any chronic and ultimately fatal illness. This shift was important because if a disease-oriented approach is followed, the needs and preferences of the patient are not fully met and aspects of care, such as pain, quality of life, and social support, as well as spiritual and emotional needs, fail to be addressed. Rather, a patient-centered model prioritizes relief of suffering and tailors care to increase the quality of life for terminally ill patients.

<span class="mw-page-title-main">Pain management</span> Interdisciplinary approach for easing pain

Pain management is an aspect of medicine and health care involving relief of pain in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine.

Health psychology is the study of psychological and behavioral processes in health, illness, and healthcare. The discipline is concerned with understanding how psychological, behavioral, and cultural factors contribute to physical health and illness. Psychological factors can affect health directly. For example, chronically occurring environmental stressors affecting the hypothalamic–pituitary–adrenal axis, cumulatively, can harm health. Behavioral factors can also affect a person's health. For example, certain behaviors can, over time, harm or enhance health. Health psychologists take a biopsychosocial approach. In other words, health psychologists understand health to be the product not only of biological processes but also of psychological, behavioral, and social processes.

Disease management is defined as "a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant."

A chronic condition is a health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term chronic is often applied when the course of the disease lasts for more than three months. Common chronic diseases include diabetes, functional gastrointestinal disorder, eczema, arthritis, asthma, chronic obstructive pulmonary disease, autoimmune diseases, genetic disorders and some viral diseases such as hepatitis C and acquired immunodeficiency syndrome. An illness which is lifelong because it ends in death is a terminal illness. It is possible and not unexpected for an illness to change in definition from terminal to chronic. Diabetes and HIV for example were once terminal yet are now considered chronic due to the availability of insulin for diabetics and daily drug treatment for individuals with HIV which allow these individuals to live while managing symptoms.

<span class="mw-page-title-main">Self-care</span> Taking care of ones own health

Self-care has been defined as the process of establishing behaviors to ensure holistic well-being of oneself, to promote health, and actively manage illness when it occurs. Individuals engage in some form of self-care daily with food choices, exercise, sleep, and hygiene. Self-care is not only a solo activity, as the community—a group that supports the person performing self-care—overall plays a role in access to, implementation of, and success of self-care activities.

Psycho-oncology is an interdisciplinary field at the intersection of physical, psychological, social, and behavioral aspects of the cancer experience for both patients and caregivers. Also known as psychiatric oncology or psychosocial oncology, researchers and practitioners in the field are concerned with aspects of individuals' experience with cancer beyond medical treatment, and across the cancer trajectory, including at diagnosis, during treatment, transitioning to and throughout survivorship, and approaching the end-of-life. Founded by Jimmie Holland in 1977 via the incorporation of a psychiatric service within the Memorial Sloan Kettering Cancer Center in New York, the field has expanded drastically since and is now universally recognized as an integral component of quality cancer care. Cancer centers in major academic medical centers across the country now uniformly incorporate a psycho-oncology service into their clinical care, and provide infrastructure to support research efforts to advance knowledge in the field.

Multimorbidity, also known as multiple long-term conditions (MLTC), means living with two or more chronic illnesses. For example, a person could have diabetes, heart disease and depression at the same time. Multimorbidity can have a significant impact on people's health and wellbeing. It also poses a complex challenge to healthcare systems which are traditionally focused on individual diseases. Multiple long-term conditions can affect people of any age, but they are more common in older age, affecting more than half of people over 65 years old.

Chronic care refers to medical care which addresses pre-existing 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 asthma, diabetes, emphysema, chronic bronchitis, congestive heart disease, cirrhosis of the liver, hypertension and depression. Without effective treatment chronic conditions may lead to disability.

<span class="mw-page-title-main">Caregiver</span> Person helping another with activities of daily living

A caregiver, carer or support worker is a paid or unpaid person who helps an individual with activities of daily living. Caregivers who are members of a care recipient's family or social network, and who may have no specific professional training, are often described as informal caregivers. Caregivers most commonly assist with impairments related to old age, disability, a disease, or a mental disorder.

Patricia A. Fennell is the chief executive officer of Albany Health Management Associates. She is a clinician, research scientist, educator, and author specializing in chronic illness, chronic and post-viral syndromes, trauma, forensics, hospice, global health care concerns, autoimmune and post-viral disease, clinical education, and training.

Functional disorders are a group of recognisable medical conditions which are due to changes to the functioning of the systems of the body rather than due to a disease affecting the structure of the body.

Mindfulness-Based Stress Reduction (MBSR) is an eight-week, evidence-based program designed to provide secular, intensive mindfulness training to help individuals manage stress, anxiety, depression, and pain. MBSR was developed in the late 1970s by Jon Kabat-Zinn at the University of Massachusetts Medical Center. It incorporates a blend of mindfulness meditation, body awareness, yoga, and the exploration of patterns of behavior, thinking, feeling, and action. Mindfulness can be understood as the non-judgmental acceptance and investigation of present experience, including body sensations, internal mental states, thoughts, emotions, impulses and memories, in order to reduce suffering or distress and to increase well-being. Mindfulness meditation is a method by which attention skills are cultivated, emotional regulation is developed, and rumination and worry are significantly reduced. During the past decades, mindfulness meditation has been the subject of more controlled clinical research, which suggests its potential beneficial effects for mental health, athletic performance, as well as physical health. While MBSR has its roots in wisdom teachings of Zen Buddhism, Hatha Yoga, Vipassana and Advaita Vedanta, the program itself is secular. The MBSR program is described in detail in Kabat-Zinn's 1990 book Full Catastrophe Living.

Pediatric psychology is a multidisciplinary field of both scientific research and clinical practice which attempts to address the psychological aspects of illness, injury, and the promotion of health behaviors in children, adolescents, and families in a pediatric health setting. Psychological issues are addressed in a developmental framework and emphasize the dynamic relationships which exist between children, their families, and the health delivery system as a whole.

The Patient Activation Measure (PAM) is a commercial product which assesses an individual's knowledge, skill, and confidence for managing one's health and healthcare. Individuals who measure high on this assessment typically understand the importance of taking a pro-active role in managing their health and have the skills and confidence to do so.

Symptom targeted intervention (STI) is a clinical program being used in medical settings to help patients who struggle with symptoms of depression or anxiety or adherence to treatment plans but who are not interested in receiving outpatient mental health treatment. STI is an individualized therapeutic model and clinical program that teaches patients brief, effective ways to cope with difficult thoughts, feelings, and behaviors using evidence-based interventions. Its individualized engagement process employs techniques from solution-focused therapy, using a Rogerian, patient-centered philosophy. This engagement process ensures that even challenging, at-risk, and non-adherent patients are able to participate.

Childhood chronic illness refers to conditions in pediatric patients that are usually prolonged in duration, do not resolve on their own, and are associated with impairment or disability. The duration required for an illness to be defined as chronic is generally greater than 12 months, but this can vary, and some organizations define it by limitation of function rather than a length of time. Regardless of the exact length of duration, these types of conditions are different than acute, or short-lived, illnesses which resolve or can be cured. There are many definitions for what counts as a chronic condition. However, children with chronic illnesses will typically experience at least one of the following: limitation of functions relative to their age, disfigurement, dependency on medical technologies or medications, increased medical attention, and a need for modified educational arrangements.

Digital therapeutics, a subset of digital health, are evidence-based therapeutic interventions driven by high quality software programs to prevent, manage, or treat a medical disorder or disease. Digital therapeutic companies should publish trial results inclusive of clinically meaningful outcomes in peer-reviewed journals. The treatment relies on behavioral and lifestyle changes usually spurred by a collection of digital impetuses. Because of the digital nature of the methodology, data can be collected and analyzed as both a progress report and a preventative measure. Treatments are being developed for the prevention and management of a wide variety of diseases and conditions, including type 1 & type II diabetes, congestive heart failure, obesity, Alzheimer's disease, dementia, asthma, substance abuse, ADHD, hypertension, anxiety, depression, and several others. Digital therapeutics often employ strategies rooted in cognitive behavioral therapy.

Mindfulness-based pain management (MBPM) is a mindfulness-based intervention (MBI) providing specific applications for people living with chronic pain and illness. Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive emphasis on the practice of 'loving-kindness', and has been seen as sensitive to concerns about removing mindfulness teaching from its original ethical framework. It was developed by Vidyamala Burch and is delivered through the programs of Breathworks. It has been subject to a range of clinical studies demonstrating its effectiveness.

References

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  3. ↑ Health in Everyday Living Archived 2016-05-22 at the Portuguese Web Archive Robert Wood Johnson Foundation primer
  4. ↑ Kangovi, Shreya; Mitra, Nandita; Norton, Lindsey; Harte, Rory; Zhao, Xinyi; Carter, Tamala; Grande, David; Long, Judith A. (2018-12-01). "Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial". JAMA Internal Medicine. 178 (12): 1635–1643. doi:10.1001/jamainternmed.2018.4630. ISSN   2168-6106. PMC   6469661 . PMID   30422224.
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  6. ↑ Wellard S (1998). "Constructions of chronic illness". International Journal of Nursing Studies. 35 (1–2): 49–55. CiteSeerX   10.1.1.540.4210 . doi:10.1016/S0020-7489(98)00013-3. PMID   9695010.
  7. ↑ Burckhardt CS (September 1987). "Coping strategies of the chronically ill". Nurs. Clin. North Am. 22 (3): 543–50. doi:10.1016/S0029-6465(22)01305-6. PMID   3649790. S2CID   31337575.
  8. ↑ Baker C, Stern PN (1993). "Finding meaning in chronic illness as the key to self-care". Can J Nurs Res. 25 (2): 23–36. PMID   8118760.
  9. ↑ Lubkin, I.M. and Larson, P.D. (2002). Chronic illness: Impact and interventions (5th ed.) Sudbury, MA: Jones and Bartlett.
  10. ↑ Register, C. (1987). The Chronic Illness Experience: Embracing the Imperfect Life. Center City MN: Hazelton.
  11. ↑ Wells, S.M. (1988). A Delicate Balance: Living Successfully With Chronic Illness. New York: Plenum Press.
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  15. ↑ Prochaska JO, DiClemente CC, Norcross JC (September 1992). "In search of how people change. Applications to addictive behaviors". Am Psychol. 47 (9): 1102–14. doi:10.1037/0003-066X.47.9.1102. PMID   1329589.
  16. ↑ Fennell, P.A. (2003). Managing Chronic Illness: The Four Phase Approach. New York: Wiley. Archived from the original on 2008-08-28. Retrieved 2008-05-12.
  17. ↑ Fennell, P.A. (2006). The Chronic Illness Workbook: Strategies and Solutions for Taking Back Your Life (2nd ed.). Delmar NY: Spring Harbor Press.
  18. ↑ "Wyatt Matas : Thought Center". Archived from the original on 2013-06-30. Retrieved 2013-04-07.
  19. ↑ "Archived copy" (PDF). Archived from the original (PDF) on 2015-06-20. Retrieved 2015-06-19.{{cite web}}: CS1 maint: archived copy as title (link)
  20. ↑ Steven, Mark. "Chronic pain relief" . Retrieved 13 September 2023.
  21. ↑ Peytremann-Bridevaux, I; Arditi, C; Gex, G; Bridevaux, PO; Burnand, B (2015). "Chronic disease management programmes for adults with asthma". Cochrane Database of Systematic Reviews. 2015 (5): CD007988. doi:10.1002/14651858.CD007988.pub2. PMC   10640711 . PMID   26014500.
  22. ↑ Mehan, Suraj; Morris, Julia (2018). "A literature review of Breathworks and mindfulness intervention". British Journal of Healthcare Management. 24 (5): 235–241. doi:10.12968/bjhc.2018.24.5.235. ISSN   1358-0574.
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  24. ↑ Brown, CA; Jones, AKP (2013). "Psychobiological Correlates of Improved Mental Health in Patients With Musculoskeletal Pain After a Mindfulness-Based Pain Management Program". The Clinical Journal of Pain. 29 (3): 233–44. doi:10.1097/AJP.0b013e31824c5d9f. PMID   22874090. S2CID   33688569.
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