Chronic care management

Chronic care management encompasses the oversight and education activities conducted by professionals to help patients with chronic diseases 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.

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.

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.

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, a number of pioneering researchers began to investigate the issues that they found existed in 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 recognized 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 significant recommendations about how to manage living with 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.

E. Wagner developed a Chronic Care Model that provides a holistic framework and methodology for transforming health care so that patients receive coordinated care from a trained interdisciplinary health care team that includes a planned follow-up.

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 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. FFPM outlines four phases that people commonly experience as they learn to incorporate their changed physical abilities or psychological outlook into their personality and lifestyle: Crisis, Stabilization, Integration, and Resolution.

All of this seminal work recognizes that time itself -- the changing actualities and perceptions that chronic illness patients have of their illness and the changing interventions required as time passes -- determines how chronic illnesses can be best managed. The conceptual frameworks that appear to offer the most promising results are those that focus on where patients are on a time continuum -- that is, what phase they are in. Moreover, although the phases were first utilized in treatment of patients with traditional chronic diseases like MS and lupus, they apply equally well to those who survive a stroke, manage persistent heart disease, or undergo regular kidney dialysis.

For Further Reading

 * Albany Health Management Associates
 * Improving Chronic Illness Care
 * Partnership for Solutions
 * Stanford Self-Management Program