Living Well with Chronic Illness A Call for Public Health Action (2012) / Chapter Skim
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Appendix B: New Models of Comprehensive Health Care for People with Chronic Conditions--Chad Boult and Erin K. Murphy
Appendix B: New Models of Comprehensive Health Care for People with Chronic Conditions--Chad Boult and Erin K. Murphy
Pages 285-318
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It has several goals: • Identify new models of comprehensive health care that have been reported to improve the functional autonomy or overall quality of chronically ill people's lives. • Describe the goals, target populations, and operational features of these models.
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• Internet searches for reports posted between June 1, 2008, and June 30, 2011, to obtain information about other promising mod els of chronic care, research about which has not yet been peer reviewed or published in scientific journals. From among 15 models of comprehensive care that have been shown to improve life significantly for chronically ill persons, we identified 6 that integrate medical and community-based care: • Transitional care • Caregiver education and support • Chronic disease self-management • Interdisciplinary primary care • Care/case management • Geriatric evaluation and management In the future, other new models of comprehensive care may also be shown to improve functional autonomy and quality of life.
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Unless scientists make unprecedented breakthroughs in preventing or curing chronic conditions soon, the United States will face growing pandemics of chronic disease and disability throughout the next several decades. America's providers of health care and supportive services have not yet developed the capacity to provide high-quality, comprehensive chronic care.
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to identify comprehensive models that have, in high-quality studies, produced significant improvements in the functional autonomy or quality of life of chronically ill persons. We considered a model to be comprehensive if it addresses multiple health-related needs of adults, that is, the model provides care for several chronic condi tions, for several aspects of one condition, or for persons receiving care from several health care providers.
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• Internet searches for reports posted between June 1, 2008, and June 30, 2011, to obtain information about other promising mod els of chronic care, research about which has not yet been peer reviewed or published in scientific journals. PROMISING MODELS OF COMPREHENSIVE CHRONIC CARE Numerous new models of care for people with chronic conditions have been proposed, created, tested, and promoted in recent years.
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Section A: Comprehensive models of health care reported in peer-reviewed journals to produce statistically significant improvements in the quality of life or the functional autonomy of persons with chronic conditions. MEDLINE reviews of the scientific literature from January 1987 through June 2011 identified 15 successful models of comprehensive care for persons with chronic conditions (Models A-O in Table B-1)
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strives to enhance chronically ill patients' functional autonomy and quality of life. In each, comprehensive care is provided by interdisciplinary teams composed of a primary care physician and one or more other co-located health care professionals, such as nurses, social workers, nurse practitioners, or rehabilitation therapists, who communicate regularly with each other.
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Care managers are usually employees of health insurers or capitated health care provider organizations. CM has been shown fairly consistently to improve patients' quality of life, less so their functional autonomy.
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A meta-analysis of heart failure programs, however, reported that DM was associated with significantly fewer hospital admissions. A subsequent randomized controlled trial (RCT)
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Chronic disease self-management (CDSM) programs are structured, time-limited interventions designed to provide health information and empower patients to assume an active role in managing their chronic conditions, often through the use of community-based services.
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Caregiver education and support programs are designed to help informal/family caregivers to enhance the well-being of their loved ones with chronic conditions. Led by psychologists, social workers, or rehabilitation therapists, these programs provide varying combinations of health information, training, access to professional and community resources, emotional support, counseling, and information about coping strategies.
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Most transitional care programs have been sponsored by health insurers or capitated health care provider organizations. Transitional care is consistently successful in improving patients' quality of life and reducing their readmissions to hospitals (Coleman et al., 2006; Naylor et al., 2004; Phillips et al., 2004)
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Comprehensive hospital care models include interdisciplinary geriatric consultation teams, acute care for elders (ACE) units, comprehensive
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Section B: Comprehensive models of health care claimed in non-peer-reviewed reports to improve the quality of life or the functional autonomy of persons with chronic conditions. Collaborative Medical Homes Collaborative medical homes are primary care practices that collaborate with community-based agencies -- rather than expanding their intramural staff and operations -- to provide comprehensive medical home services to their patients.
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In each network, physician practices (medical homes) collaborate with hospitals, local health departments, and social service agencies to provide comprehensive care -- including care management -- for the majority of North Carolina's Medicaid enrollees.
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G Chronic disease X 1 meta-analysis Lower use (4/5)
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includes meta-analysis; ↑ = better outcome; LOS = length of stay in hospital; NA = not assessed; ND = no difference; QE = quasi-experimental, RCT = randomized controlled trial, XS = cross-sectional. Fractions: numerator = number of studies showing significant difference, denominator = number of studies in which this outcome was assessed.
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in Puget • Sound, WA The IOCP aims to improve the quality of health care while reduc ing the costs of care for patients predicted to incur high health care costs. For each patient, a registered nurse/case manager conducts a comprehensive evaluation, develops a care plan, promotes patient self-management of chronic diseases, and confers with the patient's primary care physician through regular "huddles." IOCP patients' scores on functional independence and depression improved from baseline, but these scores were not compared with a control group.
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CareMore patients undergo a com prehensive physical exam with a detailed medical history and are then triaged to appropriate chronic disease management teams. A nurse practitioner is the focal point of the care team, which relies on health information technology and remote monitoring to track patients' status.
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A multidisciplinary team of nurse practitioners, geri atric social workers, and other clinic- and community-based staff conducts comprehensive assessments and arranges a wide array of services, including transportation and escorts to appointments, to promote independent functioning by patients with chronic condi tions. Unpublished data suggest that Senior Care Options improves the quality of care for chronically ill patients and reduces their use of hospitals and nursing homes, as well as their overall health care costs (AHRQ; Meyer, 2011)
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Additional new models of comprehensive chronic care (e.g., collaborative medical homes, complex clinics) may be shown in the future to improve chronically ill persons' functional autonomy and quality of life, but high-quality scientific evidence of such effects is currently lacking.
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We do not know, for example, whether the additional costs incurred by integrating community-based services into a pri mary care practice, most of which are driven by additional staff time, can be justified by better quality of life or greater functional independence for the practice's chronically ill patients. We also do not know whether such integration would increase, decrease, or have no effect on the overall costs of comprehensive care for such patients.
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2003. The expanded Chronic Care Model: An integration of concepts and strategies from population health promotion and the Chronic Care Model.
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2002. Improving primary care for patients with chronic illness: The chronic care model, Part 2.
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in a community hospital. Journal of the American Geriatrics Society 48(12)
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Journal of the American Geriatrics Society 57(8)
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Journal of the American Geriatrics Society 54(5)
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2007. Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial.
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Journal of the American Geriatrics Society 53(3)
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Journal of the American Geriatrics Society 53(2)
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2004. A chronic disease management programme can reduce days in hospital for patients with chronic obstructive pulmonary disease.
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A prospective randomized trial. Journal of the American Geriatrics Society 50(5)
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2005. Meta analysis and review of heart failure disease management randomized controlled clinical trials.
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