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Disease Management and the Organization of Physician Practice
Abstract
There is a large gap between what physicians do for patients with chronic
diseases and what should be done.1 Most physicians
lack the time, information technology, and financial incentives to develop
organized processes to systematically improve the quality of care provided
to these patients.2 During the past decade,
2 main models have emerged to address this “quality chasm” in
outpatient care: disease management and the chronic care model. Early in 2005,
the Center for Medicare & Medicaid Services (CMS) will begin a large disease
management initiative that may profoundly impact patient care and the organization
of physician practice. But few physicians are aware of this initiative, and
in general, neither disease management, nor the chronic care model are easily
understood. Neither model appears in the index of a major collection of essays
on medical group practice published in 2004.3 This
article will describe the CMS initiative, and describe and compare the disease
management and chronic care model models and the effects they may have on
physician practice and on patient care.
... Asthma mortality increased by 3.4% every year from 1979 to 1998 amounting to about 2.2 deaths per 100,000 people or about 4,200 deaths on a nationwide basis. Casalino 2005). Recently, there has been a drop in the mortality rates due to successful implementation of clinical guidelines for asthma treatment (National Asthma Education and Prevention Program, 1997). ...
... Partially capitated plans allowed for some risk-sharing between the Medicaid agency and the MMC plans (Casalino 2005;Çelik et al. 2004;Gendo et al. 2003;Godard 2002;. Under the Fee-For-Service Primary Care Case Management (PCCM) model, primary care practitioners (PCPs) act as gatekeepers to determine the eligibility of services being provided to beneficiaries. ...
... Managed care and financial incentives programs are putting limits on physicians' autonomy in drug prescribing (Casalino 2005;). As the services provided by physicians expand beyond a single managed care plan, physicians will have to develop skills for managing multiple formularies. ...
It is believed that health plans, reimbursement mechanisms and financial incentives led to health outcomes for health care utilization and medication adherence from pediatric populations. However, there is little empirical evidence about the effect of health plans, reimbursement mechanisms and financial incentives on asthmatic pediatric population.
The first study examined how sociological factors including financial incentives influenced whether asthmatic children received a controller medication, a reliever medication or both. The 2007 National Ambulatory Medical Care Survey was used for this analysis. Compared with physicians who received lower financial incentives, physicians who received medium (39%, p
... The importance of patients' self-management of their long-term disease, particularly with cancer (categorized by the WHO as a chronic illness), including daily decision-making regarding their treatment, physical activity or diet, has been well-established. [3,4] The number of patients treated on an outpatient basis is increasing, while the length of hospitalization stays is decreasing, leading to more complex pathways of care. [5] Improving the "performance" of care requires a gradual empowerment of patients. ...
... 2. Describe modalities of care of the cancer patient treated by intravenous means. 3. Identify avenues for reflection on the specific challenges facing patient-centered care, from the perspective of changes in practices in the cancer care pathway. ...
Objective: France is experiencing a shift in health policy. The purpose of this article is to describe how cancer care health professionals define patient empowerment, describe modalities of care of the cancer patient treated by intravenous means and identify avenues for reflection on the specific challenges facing patient-centered care, from the perspective of changes in practices in the cancer care pathway.Methods: 19 individual, semi-structured interviews with health professionals working in cancer care facilities were analyzed in a qualitative study, using the Theoretical Domain Framework linked to the COM-B model.Results: The organization of care is governed by three factors. First of all, the cancer care system focuses on the strictly curative aspect of this disease. All devices lead to management centered on the pathology, and not on the patient as a whole. Secondly, the fact that the patient suffers from cancer modifies the attitudes and representations of caregivers towards the patient. Cancer introduces a relational bias in each of the stakeholders. Thirdly, the current organization of nursing care maintains paternalistic and prescriptive care in the cancer care pathway. Only new nursing jobs (coordinating nurses or pivot nurses) suggest the possibility of switching to patient-centered care. The analysis from TDF linked to the COM-B model shows that the strategy of implementing a new tool to measure the level of patient engagement, in routine nursing care, must focus on the reflective opportunity and motivation of the stakeholders.Conclusions: Caregivers should be acculturated to patient empowerment. TDF linked to the COM-B model can make it possible to think about how to prepare and adapt this change in practice at several sites of cancer treatment. Training adapted to the context to familiarize current caregivers with this new form of care is currently being implemented. To succeed, acculturating current health care providers to this new form of care, while offering them a tool to objectively assess the level of patient empowerment would undoubtedly foster their involvement in supporting patient empowerment, while allowing them to evaluate the time required to integrate this type of care.
... uznaje się także, że w ramach ccM największe znaczenie mają następujące elementy [5,40]: edukacja pacjen-tów i ich rodzin z kształtowaniem celowanych umiejętności w zakresie chorób przewlekłych występujących u pacjenta; wielospecjalistyczne zespoły organizujące spotkania z pacjentami i ich opiekunami domowymi, których głównym celem jest równorzędna wymiana doświadczeń i ewaluacja opieki; system informacji klinicznych i wsparcia w zakresie podejmowanych decyzji z identyfikacją pacjentów chorych przewlekle, wypracowaniem systemu kontroli klinicznych opartych na eBM i informacji zwrotnych na temat stanu pacjenta dla zespołu wielodyscyplinarnego, z dostarczaniem nowych i stałym monitoringiem już zaimplementowanych wytycznych wynikających z eBM [40]. ...
... uznaje się także, że w ramach ccM największe znaczenie mają następujące elementy [5,40]: edukacja pacjen-tów i ich rodzin z kształtowaniem celowanych umiejętności w zakresie chorób przewlekłych występujących u pacjenta; wielospecjalistyczne zespoły organizujące spotkania z pacjentami i ich opiekunami domowymi, których głównym celem jest równorzędna wymiana doświadczeń i ewaluacja opieki; system informacji klinicznych i wsparcia w zakresie podejmowanych decyzji z identyfikacją pacjentów chorych przewlekle, wypracowaniem systemu kontroli klinicznych opartych na eBM i informacji zwrotnych na temat stanu pacjenta dla zespołu wielodyscyplinarnego, z dostarczaniem nowych i stałym monitoringiem już zaimplementowanych wytycznych wynikających z eBM [40]. ...
It is suggested that health systems should be modeled on the structure supporting the "management of chronic diseases" - depending of course on local capabilities, the needs and expectations of patients. For many years, there has been a need to define the system of care within the home environment of patients, focused on the individual health needs of patients. It has been shown that home care has a high clinical efficacy with lower risk of hospitalization and increased satisfaction ratings. It is assumed that the most effective level for the development and smooth functioning of the system of care for the chronically ill is the primary health care administered by a multidisciplinary team of professionals, led primarily for chronically ill patients and their bio-psycho-social needs. More and more interest has also been associated with an attempt to shape health care in meeting the expectations of chronically ill patients and simultaneous evolution of reactive system (responsive when a person is already sick) to proactive (seeking to maintain a high level of quality of life). These elements should be realized by Chronic Care Model (CC M) in the primary care setting assuming: a partnership between cooperating patients and health care professionals, cooperation within care and education complemented by support for patients in achieving the highest possible quality of life.
... 41 The value of role clarity and system support allows different team members to assume a variety of nontraditional roles with good results. 8,12,17 The lower scores on performance metrics by associate providers in relation to physicians differs from previous studies. 8,12,17 In those studies, however, the associate providers often had defined roles to assist in chronic disease management. ...
... 8,12,17 The lower scores on performance metrics by associate providers in relation to physicians differs from previous studies. 8,12,17 In those studies, however, the associate providers often had defined roles to assist in chronic disease management. In these practices, the associate providers might have had various roles, often providing urgent care and managing "overflow." ...
The "office nurse" or clinical associate (registered nurse [RN], licensed practical nurse[LPN], or medical assistant [MA]) is a key member of the family medicine care team, but little is known about the influence of their level of training on team performance.
The performance of the clinical dyad (clinician and associate) was studied in relation to the level of training of the nurse. The dyad's performance was measured by the performance indicators of diabetes scores, patient satisfaction, and productivity.
Dyads with a RN scored higher in meeting all 5 of the diabetes quality indicators (27.8%) than those with a LPN (19.3%) or an MA (14.7%). For patient satisfaction, the RN dyads also scored higher than the other dyad groups (positive responses: RN, 96.8%; LPN, 95.5%; MA, 94.6%). Productivity was the same in all groups. Better diabetes performance was seen in those practices with fewer competing demands: nonrural versus rural (22.2% vs 15.1%, respectively), and those not doing obstetrics versus those doing obstetrics (20.3% vs 15.1%, respectively), and for physicians versus associate providers (18.8% vs 15.1%, respectively). Higher patient satisfaction was observed in those dyads who were nonrural verus rural (96.6 vs 94.1%), among those doing obstetrics (96.0% vs 94.9%), and in physicians verus associate providers (95.7% vs 93.2%). The number of years working with the same clinician was twice as high for RNs (6.63) and LPNs (6.57) than for MAs (3.29).
A higher level of education of the clinical associate seems to confer skills that enhance the care team's management of chronic illness such as diabetes. This could potentially decrease the practice burden on other team members while facilitating the team's objectives in meeting quality indicators.
... More specifically, it has been shown there is an increase in large group practices, and a decline in small group practices [26]. A study that assessed the benefits and barriers of large physician group practice by Casalino and colleagues found that "single specialty groups, mainly in 5 to 20 physicians were growing" [43]. In addition, Dove and colleague found that a higher proportion of physicians are members of a medical group and the average size of group practices is rising [33,44]. ...
... In chronic disease, patient empowerment has been a key goal for several years. Specifically in oncology, the importance of long-term self-management by patients and their daily decision-making regarding their treatment, physical activity or diet are major concerns in the management and support of patients (Casalino, 2005;Lorig et al., 2001). An assessment tool measuring patient empowerment is being prepared for deployment in routine oncology nurse practice at several hospital sites. ...
... In all probability, the latter group would commit to improving their health behaviors [38,42]. The importance of the patient's role in self-management of chronic illness, including making daily decisions about treatment, physical activity, or diet, has been increasingly recognized [43,44]. A high activation level can result in improved health-friendly behaviors [45], appropriate use of the health care system [42,46], a critical perspective and participation in decision-making processes with stakeholders in the health care system [42], improved management [47] and better control of chronic diseases [48,49], and a reduction in health care costs [50]. ...
... Effective disease management requires a constant search for factors relevant to improving the quality of care and patient safety [1,2]. Analysis of affective state refers to the way the person feels at any given time. ...
Invasive or uncomfortable procedures especially during healthcare trigger emotions. Technological development of the equipment and systems for monitoring and recording psychophysiological functions enables continuous observation of changes to a situation responding to a situation. The presented study aimed to focus on the analysis of the individual’s affective state. The results reflect the excitation expressed by the subjects’ statements collected with psychological questionnaires. The research group consisted of 49 participants (22 women and 25 men). The measurement protocol included acquiring the electrodermal activity signal, cardiac signals, and accelerometric signals in three axes. Subjective measurements were acquired for affective state using the JAWS questionnaires, for cognitive skills the DST, and for verbal fluency the VFT. The physiological and psychological data were subjected to statistical analysis and then to a machine learning process using different features selection methods (JMI or PCA). The highest accuracy of the kNN classifier was achieved in combination with the JMI method (81.63%) concerning the division complying with the JAWS test results. The classification sensitivity and specificity were 85.71% and 71.43%.
... In all probability, the latter group would commit to improving their health behaviors [38,42]. The importance of the patient's role in self-management of chronic illness, including making daily decisions about treatment, physical activity, or diet, has been increasingly recognized [43,44]. A high activation level can result in improved health-friendly behaviors [45], appropriate use of the health care system [42,46], a critical perspective and participation in decision-making processes with stakeholders in the health care system [42], improved management [47] and better control of chronic diseases [48,49], and a reduction in health care costs [50]. ...
Background
The increase in the number of cancer cases and the evolution of cancer care management have become a significant problem for the French health care system, thereby making patient empowerment as a long sought-after goal in chronic pathologies. The implementation of an activation measure via the Patient Activation Measure-13 item (PAM-13) in the course of cancer care can potentially highlight the patient’s needs, with nursing care adapting accordingly.
Objective
The objectives of this PARACT (PARAmedical Interventions on Patient ACTivation) multicentric study were as follows: (1) evaluate the implementation of PAM-13 in oncology nursing practices in 5 comprehensive cancer centers, (2) identify the obstacles and facilitators to the implementation of PAM-13, and (3) produce recommendations for the dissemination of such interventions in other comprehensive cancer centers.
Methods
This study will follow the “Reach, Effectiveness, Adoption, Implementation, and Maintenance” framework and will consist of 3 stages. First, a robust preimplementation analysis will be conducted using the Theoretical Domains Framework (TDF) linked to the “Capability, Opportunity, Motivation, and Behavior” model to identify the obstacles and facilitators to implementing new nursing practices in each context. Then, using the Behavior Change Wheel, we will personalize a strategy for implementing the PAM-13, depending on the specificities of each context, to encourage acceptability by the nursing staff involved in the project. This analysis will be performed via a qualitative study through semistructured interviews. Second, the patient will be included in the study for 12 months, during which the patient care pathway will be studied, particularly to collect all relevant contacts of oncology nurses and other health professionals involved in the pathway. The axes of nursing care will also be collected. The primary goal is to implement PAM-13. Secondary factors to be measured are the patient’s anxiety level, quality of life, and health literacy level. The oncology nurses will be responsible for completing the questionnaires when the patient is at the hospital for his/her intravenous chemotherapy/immunotherapy treatment. The questionnaires will be completed thrice in a year: (1) at the time of the patient’s enrollment, (2) at 6 months, and (3) at 12 months. Third, a postimplementation analysis will be performed through semistructured interviews using the TDF to investigate the implementation problems at each site.
Results
This study was supported by a grant from the French Ministry of Health (PHRIP PARACT 2016-0405) and the Lucien Neuwirth Institute of Cancerology of Saint-Etienne, France. Data collection for this study is ongoing.
Conclusions
This study would improve the implemented targeted nursing interventions in cancer centers so that a patient is offered a personalized cancer care pathway. Furthermore, measuring the level of activation and the implementation of measures intended to increase such activation could constitute a significant advantage in reducing social health inequalities.
Trial Registration
ClinicalTrials.gov NCT03240341; https://clinicaltrials.gov/ct2/show/NCT03240341
International Registered Report Identifier (IRRID)
DERR1-10.2196/17485
... In chronic disease, patient empowerment has been a key goal for several years. Specifically in oncology, the importance of long-term self-management by patients and their daily decision-making regarding their treatment, physical activity or diet are major concerns in the management and support of patients (Casalino, 2005;Lorig et al., 2001). An assessment tool measuring patient empowerment is being prepared for deployment in routine oncology nurse practice at several hospital sites. ...
The issue of the elderly people’s rights has been discussed more and more often in the broader context of human rights. There is much evidence from social life that these rights are not being respected to the extent they should be. Securing and respecting the rights of older the elderly is becoming a challenge for state authorities that uphold human rights and create the directions of social policy for the rights protection. It is especially important as the elderly people due to their age, health status, weakened social position, rarely become advocates of their own interests. They are victims of an unobvious and often invisible process of marginalization and self-exclusion from an active social life. The aim of this article is to sketch the phenomenon of the marginalization of the elderly in the context of mechanisms related to their functioning on the one hand, and age, and on the other to social attitudes towards seniors. There are presented the elderly people’s rights and basic conditions for the rights to be respected..
... In chronic disease, patient empowerment has been a key goal for several years. Specifically in oncology, the importance of long-term self-management by patients and their daily decision-making regarding their treatment, physical activity or diet are major concerns in the management and support of patients (Casalino, 2005;Lorig et al., 2001). An assessment tool measuring patient empowerment is being prepared for deployment in routine oncology nurse practice at several hospital sites. ...
... Molti Paesi occidentali stanno orientando la propria politica sanitaria verso l'adozione di modelli assistenziali in grado di fronteggiare più efficamente la sempre crescente domanda sanitaria in questa area. Le linee di indirizzo generali si basano su modelli di gestione integrata come nuovo modo di affrontare le malattie croniche, in cui le strutture sanitarie agiscono come un sistema unitario, attorno alle esigenze complessive del paziente [15][16][17][18][19]. Infatti la sanità moderna è sempre più specializzata e richiede di ricomporre in un unico processo tutti gli interventi multidisciplinari dei diversi professionisti sanitari, in collaborazione tra loro. ...
To obtain regional and national data on the quality of diabetes care within the Italian National Health Service, a national survey among persons with diabetes was conducted in 2004. A sample of 3,426 diabetic patients (age 18-64 years) were interviewed using a standardized questionnaire. The population was middle-aged (median age 57 years), had a low educational level, and was followed primarily in public diabetes centres. A total of 54% reported having hypertension but 14% were not on treatment; for hypercholesterolemia, the corresponding figures were 44% and 26%. Of the 72% who were overweight or obese, 51% were trying to lose weight; 26% currently smoked. Only 66% of patients had undergone haemoglobin A1c testing in the past four months (among the 67% who had ever heard of test); 30% suffered from microvascular or macrovascular complications. Only 5% received all eight main tests recommended by the guidelines within the specified intervals. Our study demonstrates that diabetic patients receive less than optimal care, they are engaged in unhealthy behaviours and received inadequate treatment for comorbidities, and that the translation of guidelines into clinical practice was unsatisfactory. These data have been used to formulate national and regional policy regarding integrated case management to improve the quality of diabetes care.
... 18,19 The goal was to provide an integrated, systematic approach to population management in the primary care setting. 20 The redesign of the care delivery system established physician-led health care teams 21 with clearly defined roles and responsibilities to maximize the care they are able to provide by the scope of practice. 22 The team used practical decision support tools in the electronic health record and population management registries to identify gaps in care and coordinate interventions for preventive screening and the management of chronic conditions. ...
Objectives:
At Kaiser Permanente, national Equitable Care Health Outcomes (ECHO) Reports with a baseline measurement of 16 Healthcare Effectiveness Data and Information Set measures stratified by race and ethnicity showed a disparity of 8.1 percentage points in blood pressure (BP) control rates between African- American/black (black) and white members. The aims of this study were to describe a population care management team-based approach to improve BP control for large populations and to explain how a culturally tailored, patient-centered approach can address this racial disparity.
Methods:
These strategies were implemented through: 1) physician-led educational programs on treatment intensification, medication adherence, and consistent use of clinical practice guidelines; 2) building strong care teams by defining individual roles and responsibilities in hypertension management; 3) redesign of the care delivery system to expand access; and 4) programs on culturally tailored communication tools and self-management.
Results:
At a physician practice level where 65% of patients with hypertension were black, BP control rates (< 140/90 mmHg) for blacks improved from 76.6% to 81.4%, and control rates for whites increased from 82.9% to 84.2%. The racial gap narrowed from 6.3% to 2.8%. As these successful practices continue to spread throughout the program, the health disparity gap in BP control has decreased by 50%, from 8.1% to 3.9%.
Conclusion:
A sustainable program to collect self-reported race, ethnicity, and language preference data integrated with successful population care management programs provided the foundation for addressing health disparities. Cultural tailoring of a multilevel team-based approach closed the gap for blacks with hypertension.
... There are a number of strategic approaches for conceptualizing chronic care including the chronic care model (Wagner 1998), the innovative care for chronic conditions (WHO 2002), the public health model (Robles 2004), and the continuity of care model (McGonigle et al. 1992). All these approaches acknowledge that a substantial portion of chronic care takes place outside hospitals (Bodenheimer et al. 2002) and integrate a number of elements into a plausible package designed to create informed, active patients with improved selfmanagement skills for their chronic illnesses (Casalino 2005 ) as well as reorganize community-based care delivery systems to improve the quality of care (Rothman and Wagner 2003). ...
In this study, we propose a methodological framework to provide a road map to clinicians and system planners in developing chronic disease management strategies, and designing community-based care. We extend the analytical epidemiologic model by utilizing a patient flow approach, in order to model the multiple care-provider visit patterns of patients with a specific chronic illness. The patterns of care received by a group of patients are represented in compact form by means of a Markov model that is based on a disease-specific state space. Our framework also reflects the case-mix biases as well as the care-provider level clustering of the patients. By using this approach, we identify the patterns of care, determine the care provider and patient characteristics associated with optimal management of care, and estimate the potential influence of various interventions. The framework is applied to the data of 4000+ stroke patients discharged from the acute care hospitals of Quebec to their homes. Our findings provide a basis for designing community-based care initiatives for stroke survivors in the province.
... Their talent is needed to efficiently define and measure not only the elements of webbased, telephonic, and computer-assisted integration that result in better outcomes at lower cost, but to tell us what are the most effective mutually supportive combinations of these interventions, with or without the other emerging initiatives in primary care settings, including the core EHR, pay-for-performance, the chronic care model, and disease management. 23 Indeed, the latter is especially vital, as many commercial disease management organizations are already using many of these same web, interactive voice response, and computer support technologies with considerable commercial success. 24 Despite the limited number of studies, it is not a question of ''if,'' or even ''when'' for computer-assisted interactive technology. ...
... Like disease management, the "chronic care model," as it is known, aims to improve patient self-management by communicating with patients in their homes; unlike disease management, however, it also calls for physicians to reorganize their office practices to focus more on chronic, rather than acute, illnesses. This focus is achieved by providing patients who have chronic conditions with self-management support (such as patient education); employing multidisciplinary teams that include nonphysician staff; providing case management for the most seriously ill or frailest patients; and developing clinical information support systems that remind physicians to use evidence-based practice guidelines, and that can provide the teams with feedback about their performance (Casalino 2005). A review of 39 chronic care model programs for patients with diabetes showed that 32 improved at 6 EXHIBIT I.1 ...
Care for beneficiaries with chronic illnesses, such as heart disease and diabetes, is a major expense to the Medicare program, and a major detriment to beneficiaries’ quality of life. The Medicare Coordinated Care Demonstration is testing whether case management and disease management programs can lower costs and improve patient outcomes and well-being in the Medicare fee-for-service population. This publication, the source for a recent report to Congress, details findings from 15 programs during the first two years of Mathematica’s study, the largest random assignment study to date of disease management/case management programs. The report focuses on program impacts over the first year after enrollment for beneficiaries who enrolled during the first year, and over the first 25 months of operation for all enrollees. Findings include program-specific estimates of impacts on survey-based measures of patients’ health status, knowledge, behavior, satisfaction with their health care, quality of care, and quality of life; and claims-based measures of patients’ Medicare service use and expenditures, and the quality of care received. The findings in brief indicate that patients and physicians were generally very satisfied with the program, but few programs had statistically detectable effects on patients’ behavior or use of Medicare services.
... Like disease management, the "chronic care model," as it is known, aims to improve patient self-management by communicating with patients in their homes; unlike disease management, however, it also calls for physicians to reorganize their office practices to focus more on chronic, rather than acute, illnesses. This focus is achieved by providing patients who have chronic conditions with self-management support (such as patient education); employing multidisciplinary teams that include nonphysician staff; providing case management for the most seriously ill or frailest patients; and developing clinical information support systems that remind physicians to use evidence-based practice guidelines, and that can provide the teams with feedback about their performance (Casalino 2005). A review of 39 chronic care model programs for patients with diabetes showed that 32 improved at 6 EXHIBIT I.1 ...
... The U.S. Government Congressional Budget Office (2004), after reviewing the available literature on the topic, concluded, "There is insufficient evidence to conclude that disease management programs can generally reduce the overall cost of health care service" (p. 1). Casalino (2005) echoed this sentiment in a recent editorial in the prestigious medical journal affiliated with the American Medical Association. Finally, Fireman, Bartlett and Selby (2004), in an analysis of the experience with DM by the Kaiser Permanente Health System appearing in the widely read policy journal Health Affairs, noted savings from DM have yet to be realized. ...
... On a macro level, how well does the current system serve the chronically ill? Tens of surveys and audits have shown that large numbers of chronically ill people are not receiving highquality care, have problems controlling their conditions, and are not satisfied with their medical care (Bodenheimer, Wagner, & Grumbach, 2002;Casalino, 2005;Wagner, 1997;Wennberg, Fisher, Baker, Sharp, & Bronner, 2005). While consistent management of chronic illness has the potential to reduce complications, improve patients' quality of life, and reduce the cost of care, in reality chronic disease sufferers tend to receive episodic, crisisoriented, uncoordinated care, with sporadic follow-up and inadequate support to manage their illnesses themselves. ...
The challenge of eliminating disparities in chronic illness in the United States is hampered by the diversity of the epidemiology of the chronic conditions themselves, and by the individuality of the communities and patients affected by them. This article outlines some of the ways in which the complexity of chronic illness in underserved communities in the United States limits the data and the strategies available to clinicians and patients. We then present the example of chronic heart failure (CHF) to illustrate a possible solution that we are developing for supporting underserved patients' self- management of chronic illness: individualized health care (through "personal normals" derived from the patient's own clinical history combined with population-based data), and distributed health care (point of care through wireless biosensors and community health workers). We present some of the possible barriers to the implementation of the model. Conclusion: we believe that this approach is a pathway to empowering CHF patients in underserved communities. Further research is necessary to test the clinical viability of the model and the acceptability of the model for patients, physicians, and families.
... The importance of patients' role in self-managing chronic illness-including making daily decisions about medication, exercise, and diet-is increasingly becoming recognized. 1,2 The MMA includes provisions to improve chronic illness care through the use of disease management programs. 3 These programs, run by health plans and disease management organizations, are specifically intended to educate beneficiaries with severe chronic conditions on how to self-manage their conditions. ...
... The Wagner CCM [3,48] is one of the most widely adopted frameworks that shares these features. The CCM is considered one of the most effective treatment models because of its focus on organizational change, patient activation strategies and, unlike disease management models [49], facilitated coordination of care across existing providers (e.g. primary care providers, mental health specialists). ...
Integrated care for bipolar disorder: current evidenceBridging the divide: treatment models to integrate patient careA collaborative care model for bipolar disorderConclusion
References
... A gap exists between professionals' management of patients with chronic diseases and the desired extent of such management [17]. This disparity raises questions about the functioning of disease-management partnerships and the ability of participating professionals to create synergy that improves chronic-illness care. ...
This study explored associations among disease-management partnership functioning, synergy and effectiveness in the delivery of chronic-illness care.
This study had a cross-sectional design.
The study sample consists of 218 professionals (out of 393) participating in 22 disease-management partnerships in various regions of the Netherlands.
We assessed the relationships among partnership functioning, synergy and effectiveness in the delivery of chronic-illness care. Partnership functioning was assessed through leadership, resources, administration and efficiency. Synergy was considered the proximal outcome of partnership functioning, which, in turn, influenced the effectiveness of disease-management partnerships [measured with the Assessment of Chronic Illness Care (ACIC) survey instrument].
Overall ACIC scores ranged from 3 to 10, indicating basic/intermediate to optimal/comprehensive delivery of chronic-illness care. The results of the regression analysis demonstrate that partnership effectiveness was positively associated with leadership (β = 0.25; P≤ 0.01), and resources (β = 0.31; P≤ 0.001). No significant relationship was found between administration, efficiency and partnership effectiveness. Partnership synergy acted as a mediator for partnership functioning and was statistically significantly associated with partnership effectiveness (β = 0.25; P≤ 0.001).
Disease-management partnerships seemed better able to deliver higher levels of chronic-illness care when synergy is created between partners. Synergy was more likely to emerge with boundary-spanning leaders who understood and appreciated partners' different perspectives, could bridge their diverse cultures and were comfortable sharing ideas, resources and power. In addition, the acknowledgement of and ability to use members' resources are valuable in engaging partners' involvement and achieving synergy in disease-management partnerships.
Background
Florence Nightingale lamented that nurses were seen as merely obedient and devoted. Our two previous oncology studies demonstrated the continuum of strictly curative care and paternalistic care practices among healthcare professionals. At a time when France has just formalised the nursing sciences, this article seeks to shed light on the specifics of the nursing role in oncology and the evolution of standard nursing practices in a rapidly changing environment.
Methods
We performed a secondary qualitative analysis, on the same dataset, focusing only on the nursing population (n = 20). The COREQ guidelines were used to ensure the rigorous reporting of this study.
Findings
The data analysis show that the inherent role and application of medical directives characterise the profession of nursing in oncology. The former is essentially an intermediary role, whereby the nurse directs the patient to a professional specialist for a problem identified through clinical nursing expertise. The latter is expressed through the application of various medical instructions. The results highlight a minor evolution in nursing practices, despite an evolving environment. Oncology nurses do not seem to authorise themselves to become agents of change.
Conclusion
Various reforms and studies of the nursing profession, as well as public funding of programmes dedicated to nursing research were designed to facilitate the integration of Evidence Based Practice to encourage the autonomy of nurses in their practices.Education in research is fundamental to awakening critical thinking and considering scientific validity as vital. Continuing education and leadership by advanced practice nurses are two strong levers to acculturate registered nurses to gaining empowerment, improving their ability to question practices, helping them adapt to increasing the quality of care and making oncology nursing care more efficient. For cancer nurses in France, research education is the challenge to be met.
Full text available here : https://authors.elsevier.com/a/1cw9f-CmUs0Wm
Provision of dietary counseling in the office setting is enhanced by using team-based care and electronic tools. Effective provider-patient communication is essential for fostering behavior change: the key component of lifestyle medicine. The principles of communication and behavior change are skill-based and grounded in scientific theories and models. Motivational interviewing and shared decision making, a collaboration process between patients and their providers to reach agreement about a health decision, is an important process in counseling. The stages of change, self-determination, health belief model, social cognitive model, theory of planned behavior, and cognitive behavioral therapy are used in the counseling process.
An estimated 99 million Americans live with chronic illness. The majority have not received effective treatment or optimal disease control.1 Health services research indicates that it is the design of the care system, not the specialty of the physician or allied health professional, that is the primary determinant of the quality of chronic care.
Phase I of the voluntary chronic care improvement (CCR) under traditional fee-for-service Medicare initiative seeks to extend the benefits of disease management to an elderly population with comorbid chronic medical conditions. Active, sustained involvement of treating physicians, a historical deficit of disease management programs, is a CCI-I program goal. During the last decade, Kaiser Permanente, an integrated health care delivery system with more than 60 years of experience in managing the care of individuals and populations, has applied the chronic care model (CCM) to develop care management strategies for populations of patients with chronic medical conditions. Physician leadership and involvement have been key to successfully incorporating these practices into care. The scope of physician involvement in leading, developing, and delivering chronic illness care management at Kaiser Permanente is described as a basis for identifying opportunities to involve practicing physicians in the CCI-I.
Community-based care (C-bC) constitutes an important element of the chronic disease management programs. The design and management of C-bC systems requires the development of new resources and services, the assessment and reorganization of the existing services/facilities as well as the design of interventions. Quantitative decision models can play a major role for helping care providers and policy makers in this context. We present a systematic view of C-bC and provide selective examples of quantitative decision models developed for various chronic diseases. We outline the building blocks of C-bC systems as well as the distinguishing features of these systems that need to be incorporated in quantitative decision models. Then, we present three representative and diverse examples of prevailing quantitative approaches for managing C-bC. Finally, we discuss some avenues for future research.
The identification, treatment, and control of diabetes complications and the major risk factors for cardiovascular disease can reduce the morbidity and mortality associated with diabetes. This chapter reviews the results from different meta-analyses and reviews designed to address the effectiveness of different interventions. It describes interventions aimed at the health care system and health care providers, interventions aimed at individuals, and features of these interventions associated with their success. Finally, the chapter looks at implications for policy.
Esta Estrategia para el Abordaje de la Cronicidad en el Sistema Nacional de Salud es fruto del acuerdo y consenso entre el Ministerio de Sanidad, Servicios Sociales e Igualdad, las Comunidades Autónomas y representantes de sociedades científicas y asociaciones de pacientes. El presente documento establece objetivos y recomendaciones que permitirán orientar la organización de los servicios hacia la mejora de la salud de la población y sus determinantes, la prevención de las condiciones de salud y limitaciones en la actividad de carácter crónico y su atención integral. Ello facilitará un cambio de enfoque en el Sistema Nacional de Salud que pasará de estar centrado en la enfermedad a orientarse hacia las personas, de manera que la asistencia sanitaria resulte adecuada y eficiente y se garantice la continuidad en los cuidados.
With the ageing population and therapeutic advances in acute and chronic disease treatment, more patients are living with at least one chronic condition. The management of a patient's chronic condition is complicated by the simultaneous presence of multiple competing comorbidities and the intrapersonal and external factors that influence chronic care. The current US healthcare system is largely organised around the management of acute illness and as a result is struggling to meet the challenges of complex chronic care. These challenges require innovative strategies to improve patient care and clinical outcomes. This paper explores some of the challenges faced by patients, healthcare providers and healthcare systems, and reviews new avenues of health services research that target these challenges.
The Institute of Medicine advocates the examination of innovative models of care to expand mental health services available for older adults. This article describes training and supervision procedures in a recent clinical trial of cognitive behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD) delivered by bachelor-level lay providers (BLPs) and to Ph.D.-level expert providers (PLPs). Supervision and training differences, ratings by treatment integrity raters (TIRs), treatment characteristics, and patient perceptions between BLPs and PLPs are examined. The training and supervision procedures for BLPs led to comparable integrity ratings, patient perceptions, and treatment characteristics compared with PLPs. These results support this training protocol as a model for future implementation and effectiveness trials of CBT for late-life GAD, with treatment delivered by lay providers supervised by a licensed provider in other practice settings.
Large gaps in lipid treatment and medication adherence persist in high-risk outpatients in the United States. Health information technology (HIT) is being applied to close quality gaps in chronic illness care, but its utility for lipid management has not been widely studied.
To perform a qualitative review of the impact of HIT interventions on lipid management processes of care (screening or testing; drug initiation, titration or adherence; or referrals) or clinical outcomes (percent at low density lipoprotein cholesterol goal; absolute lipid levels; absolute risk scores; or cardiac hospitalizations) in outpatients with coronary heart disease or at increased risk.
PubMed and Google Scholar databases were searched using Medical Subject Headings related to clinical informatics and cholesterol or lipid management. English language articles that described a randomized controlled design, tested at least one HIT tool in high risk outpatients, and reported at least 1 lipid management process measure or clinical outcome, were included.
Thirty-four studies that enrolled 87,874 persons were identified. Study ratings, outcomes, and magnitude of effects varied widely. Twenty-three trials reported a significant positive effect from a HIT tool on lipid management, but only 14 showed evidence that HIT interventions improve clinical outcomes. There was mixed evidence that provider-level computerized decision support improves outcomes. There was more evidence in support of patient-level tools that provide connectivity to the healthcare system, as well as system-level interventions that involve database monitoring and outreach by centralized care teams.
Randomized controlled trials show wide variability in the effects of HIT on lipid management outcomes. Evidence suggests that multilevel HIT approaches that target not only providers but include patients and systems approaches will be needed to improve lipid treatment, adherence and quality.
American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice are systematically developed statements to assist health care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances.
Since 2003, structured treatment programs for chronically ill patients (disease management programs; DMPs) have been under development in Germany. Virtually nationwide, programs in which physicians and patients can register are being offered for diabetes mellitus types 1 and 2, breast cancer, coronary heart disease and asthma/COPD. The medical content of the programs is determined on the basis of evidence-based medicine.
Even though the effectiveness of structured treatment programs is documented for diabetes, adequate studies confirming the overall transferability of results to the German health care system are as yet lacking. Physicians above all strongly criticise the coupling of DMPs with the risk adjustment scheme of the statutory health insurance funds, as well as the large amount of paperwork involved.
Persons with bipolar disorder experience a disproportionate burden of medical conditions, notably cardiovascular disease (CVD), leading to impaired functioning and premature mortality. We hypothesized that the Life Goals Collaborative Care (LGCC) intervention, compared to enhanced usual care, would reduce CVD risk factors and improve physical and mental health outcomes in US Department of Veterans Affairs patients with bipolar disorder.
Patients with an ICD-9 diagnosis of bipolar disorder and ≥ 1 CVD risk factor (N = 118) enrolled in the Self-Management Addressing Heart Risk Trial, conducted April 2008-May 2010, were randomized to LGCC (n = 58) or enhanced usual care (n = 60). Life Goals Collaborative Care included 4 weekly self-management sessions followed by tailored contacts combining health behavior change strategies, medical care management, registry tracking, and provider guideline support. Enhanced usual care included quarterly wellness newsletters sent during a 12-month period in addition to standard treatment. Primary outcome measures included systolic and diastolic blood pressure, nonfasting total cholesterol, and physical health-related quality of life.
Of the 180 eligible patients identified for study participation, 134 were enrolled (74%) and 118 completed outcomes assessments (mean age = 53 years, 17% female, 5% African American). Mixed effects analyses comparing changes in 24-month outcomes among patients in LGCC (n = 57) versus enhanced usual care (n = 59) groups revealed that patients receiving LGCC had reduced systolic (β = -3.1, P = .04) and diastolic blood pressure (β = -2.1, P = .04) as well as reduced manic symptoms (β = -23.9, P = .01). Life Goals Collaborative Care had no significant impact on other primary outcomes (total cholesterol and physical health-related quality of life).
Life Goals Collaborative Care, compared to enhanced usual care, may lead to reduced CVD risk factors, notably through decreased blood pressure, as well as reduced manic symptoms, in patients with bipolar disorder.
ClinicalTrials.gov identifier: NCT00499096.
To propose a combined disease management and process modeling approach for evaluating and improving care processes, and demonstrate its usability and usefulness in a real-world fall management case study.
We identified essential disease management related concepts and mapped them into explicit questions meant to expose areas for improvement in the respective care processes. We applied the disease management oriented questions to a process model of a comprehensive real world fall prevention and treatment program covering primary and secondary care. We relied on interviews and observations to complete the process models, which were captured in UML activity diagrams. A preliminary evaluation of the usability of our approach by gauging the experience of the modeler and an external validator was conducted, and the usefulness of the method was evaluated by gathering feedback from stakeholders at an invitational conference of 75 attendees.
The process model of the fall management program was organized around the clinical tasks of case finding, risk profiling, decision making, coordination and interventions. Applying the disease management questions to the process models exposed weaknesses in the process including: absence of program ownership, under-detection of falls in primary care, and lack of efficient communication among stakeholders due to missing awareness about other stakeholders' workflow. The modelers experienced the approach as usable and the attendees of the invitational conference found the analysis results to be valid.
The proposed disease management view of process modeling was usable and useful for systematically identifying areas of improvement in a fall management program. Although specifically applied to fall management, we believe our case study is characteristic of various disease management settings, suggesting the wider applicability of the approach.
Care of chronic patients poses clinical and organizational challenges that are deficiently resolved in the daily practice. The key question is achievement of maximum quality of life. Chronic health problems do not generally pose diagnostic or therapeutic challenges, but those of organization and cooperation (between health care levels and between these with social services, with the patient and their family). Thus, care to patients with heart failure is deficient worldwide, also in Spain. Response to this deficiency is not generally improvement of primary care but rather its substitution by specialized care. Thus, super-specialized programs have been developed. These are dependent on heart failure hospital units, and obtain unquestionable success through the providing of low technology services, characteristic of primary care. The clinical question is extensively reviewed through response to four practical questions and the importance of home care is demonstrated in this text.
Patient activation is a term that describes the skills and confidence that equip patients to become actively engaged in their health care. Health care delivery systems are turning to patient activation as yet another tool to help them and their patients improve outcomes and influence costs. In this article we examine the relationship between patient activation levels and billed care costs. In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What's more, patient activation was a significant predictor of cost even after adjustment for a commonly used "risk score" specifically designed to predict future costs. As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined patient populations, knowing patients' ability and willingness to manage their health will be a relevant piece of information integral to health care providers' ability to improve outcomes and lower costs.
Chronisch zieken hebben de toekomst The future is to chronically ill Inaugurele rede, in verkorte vorm uitgesproken bij de openbare aanvaarding van het ambt van bijzonder hoogleraar Chronische Zorg aan de Universiteit van Tilburg op 5 november 2010 door H.J.M. Vrijhoef Deze bijzondere leerstoel is een initiatief van de Stichting Bevordering Wetenschappelijk Onderzoek Chronische Zorg Chronisch zieken hebben de toekomst 3 Mijnheer de Rector Magnificus, Dames en heren, Als iets of iemand 'de toekomst heeft', worden aan dit iets of die iemand kansen of mogelijkheden op groei en/of ontwikkeling toegeschreven. Mensen met één of meerdere gezondheidsproblemen die zijn aangewezen op langdurige of chronische zorg, gaan meer mogelijkheden dan ooit krijgen om de wijze waarop zorg wordt geleverd te beïnvloeden. Dit is nodig omdat de huidige situatie, waarin het perspectief van zorgverleners in grote mate bepalend is voor het doel van systematische verbeterinitiatieven voor chronische zorg alsook hoe de impact hiervan wordt vastgesteld, ontoereikend is. Voor toekomst-bestendige zorg is vereist dat zorgverleners en patiënten een gezamenlijk doel vaststel-len, opdat allen hiernaar gaan handelen aan de hand van prestatiematen die direct zijn afgeleid van het gezamenlijke doel. Hoewel ten aanzien van het 'hebben van toekomst' de tijd zal uitwijzen of de moge-lijkheden op groei en/of ontwikkeling worden benut, is er in de chronische zorg voor niemand tijd om een afwachtende houding aan te nemen. Bijna 10 jaar geleden conclu-deerde het Institute of Medicine (IoM), op basis van de kloof tussen de wanprestaties van het Amerikaanse gezondheidszorgsysteem en hetgeen patiënten nodig hebben, dat meer van hetzelfde geen optie is om de zorg toekomstbestendig te maken. 1 Hiermee werd niet alleen gewezen op het verbeteren van het gezondheidszorgsysteem om met name het toenemende aantal chronisch zieken zorg te bieden, maar ook op de nood-zakelijke verandering in de houding van zorgverleners en die van patiënten. Die kunnen niet langer reactief zijn, zoals bij acute aandoeningen het geval is, maar moeten een pro-actieve houding aannemen om chronische ziekten te voorkomen, te behandelen en de ermee gepaard gaande complicaties te verminderen door kwalitatief hoogwaardige zorg op adequate wijze te leveren. Het zijn de twee laatstgenoemde onderwerpen waar ik mij in deze inaugurele rede op richt: 1. Wat is het op adequate wijze leveren van chronische zorg? 2. Op basis waarvan kan worden vastgesteld dat sprake is van kwalitatief hoogwaardig geleverde zorg voor chronisch zieken?
Objectives: The Institute of Medicine has called for more coordinated cancer care models that correspond to initiatives led by cancer providers and professional organizations. These initiatives parallel those underway to integrate the management of patients with chronic conditions.
Methods: We developed 5 breast cancer patient and practice management process measures based on the Chronic Care Model. We then performed a survey to evaluate patterns and correlates of these measures among attending surgeons of a population-based sample of patients diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles and Detroit (N = 312; response rate, 75.9%).
Results: Surgeon practice specialization varied markedly with about half of the surgeons devoting 15% or less of their total practice to breast cancer, whereas 16.2% of surgeons devoted 50% or more. There was also large variation in the extent of the use of patient and practice management processes with most surgeons reporting low use. Patient and practice management process measures were positively associated with greater levels of surgeon specialization and the presence of a teaching program. Cancer program status was weakly associated with patient and practice management processes.
Conclusion: Low uptake of patient and practice management processes among surgeons who treat breast cancer patients may indicate that surgeons are not convinced that these processes matter, or that there are logistical and cost barriers to implementation. More research is needed to understand how large variations in patient and practice management processes might affect the quality of care for patients with breast cancer.
Chronic diseases such as heart disease, cancer, stroke, chronic lower respiratory diseases, diabetes, Alzheimer’s disease,
and kidney disease account for seven of the top ten causes of death and account for billions of dollars of health-care expenditures
annually in the United States (Center for Disease Control, 2005; Weingarten et al., 2002). In 2007, 11% of the US population
suffered from the number one killer in the United States diagnosed heart disease (National Center for Health Statistics, 2008;
2009). The cost of medical management of heart disease alone is staggering, in 2006 it accounted for 43% of all Medicare expenditures
and 1–2% of total US health care (Foote, 2003; Stewart, 2005; Thorn et al., 2006). The management of chronic disease (CD)
strains the psychological well-being of chronically diseased individuals and their families (Levy et al., 2007; de Ridder
et al., 2008), particularly with problems such as heart disease where psychological factors such as stress, social isolation,
anxiety, depression, and type A behavior have a role in disease progression, and management of the disease requires stressful
caregiving and case management skills from unprepared family members (Hemingway and Marmot, 1999; Rozanski et al., 1999).
A large amount of evidence, including neurohumoral, inflammatory, and metabolic physiological adaptations, emphasize the importance of the individual lifestyle as a public health concern. The related burden of chronic diseases in the European Union, which could be minimized by appropriate lifestyles, requires consistent transfer of evidence-based prevention guidelines. Due to the epidemiologic importance of cardiovascular diseases and innovative health-promoting strategies in Sweden, a comparative analysis between German and Swedish practices preventing cardiovascular events in high-risk populations is presented in this paper. This qualitative analysis demonstrates that lifestyle-related risk and protective factors based on smoking, physical activity, nutrition, and psychosocial determinants are of growing importance in cardiac death prevention. Especially in Sweden, behavioral prevention is joined by condition prevention. In Germany, intersectoral rehabilitation concepts improve patient adherence to behavioral recommendations but interdisciplinary communication between different health experts needs to be improved. The health-promoting hospital composes a health professional’s interface, which is based on the understanding that behavioral risk factors are not only highly interrelated, but also require sophisticated healthcare delivery to optimize health management effectiveness.
Whereas physician support of disease management (DM) is recognized as important for improving the quality and effectiveness of care of individuals with chronic illness, little is known about physicians' perceptions of the model or their likelihood of adoption. A multivariate regression analysis was conducted of a 2008 nationally representative sample of practising physicians in the USA who had been exposed to DM programmes (n = 1615) to determine their support for DM and how attitudes differ across physicians. Results indicated that the majority of physicians believe in the quality enhancing benefits of DM programmes, but there are systematic differences in the attitudes towards DM of different types of physicians. Physicians affiliated with health maintenance organizations (HMOs) and hospital-based practices are more likely than other physicians to agree that DM programmes improve their ability to provide high-quality care to patients with chronic conditions. Minority physicians and physicians who perceive their market as more competitive, have a more positive attitude towards DM than white physicians and physicians in less competitive markets. International medical graduates hold relatively positive attitudes about the benefits of DM programmes and older physicians are more likely than their young peers to approve of DM and physicians. Physicians with a higher percentage of patients with chronic conditions are more likely to have a favourable view of DM. Specialty physicians are more likely to have a positive view of DM, and DM-exposed physicians are more likely to perceive that DM programmes lead to improved quality of care. Future study is needed to determine the reasons for these differences in attitudes and whether they can be modified by targeted information.
Despite substantial evidence that patients with cancer commonly have significant psychosocial problems, for which we have evidence-based treatments, many patients still do not receive adequate psychosocial care. This means that we risk prolonging life without adequately addressing the quality of that life. There are many challenges to improving the current situation, the major one of which is organizational. Many cancer centers lack a system of psychosocial care that is integrated with the cancer care of the patient. Psychosocial care encompasses a range of problems (emotional, social, palliative, and logistical). The integration must occur with the cancer care of the patient at all stages (from screening to palliative care) and across all clinical sites of care (inpatient and outpatient cancer services as well as primary care). In this article, we consider the challenges we face if we are to provide such integrated psychosocial services. We focus on the collaborative care service model. This model comprises systematic identification of need, integrated delivery of care by care managers, appropriate specialist supervision, and the stepping of care based on systematic measurement of outcomes. Several trials of this approach to the management of depression in patients with cancer have found it to be both feasible to deliver and effective. It provides a model for services to meet other psychosocial needs. We conclude by proposing the key components of an integrated psychosocial service that could be implemented now and by considering what we need to do next if we are to succeed in providing better and more comprehensive care to our patients.
Hospital admissions due to exacerbations of chronic obstructive pulmonary disease (COPD) have a major impact on disease progression and costs. We hypothesized that a 1-year integrated care (IC) programme comprising two components (patient-centred education+case management) would be effective in preventing COPD-related hospitalizations.
This was a retrospective longitudinal cohort study. Data were retrieved both from an administrative database in the province of Quebec (Canada), and from the medical records at two hospitals in Montreal. One hundred and eighty-nine COPD patients were randomly selected from registers at these centres, from 2004 to 2006. Patients in the intervention group underwent a programme comprising two components: patient -centred education-involving three group sessions of self-management education that included one motivational interview and instruction in the use of a written action plan; and case management-involving scheduled follow-up visits with access to a call centre. The intervention group was compared with a group receiving usual care (UC). The main outcome was COPD-related re-hospitalizations, with length of hospital stay and emergency department (ED) visits being secondary outcomes.
Logistic regression analysis with adjustment for covariates showed that there was a lower probability of re-hospitalization over the follow-up year in the IC group compared with the UC group (odds ratio 0.44; 95% confidence interval 0.23-0.85). Subgroup analyses revealed that the IC programme prevented more COPD-related hospitalizations in women compared with men. There were no significant between-group differences in length of hospital stay or number of ED visits.
An IC programme combining self-management education and case-management can decrease rates of COPD-related hospitalizations, particularly among women.
This article reports on an action research project to investigate the barriers to adoption and assimilation of electronic health records (EHRs) in small physician practices. The project draws on theories of technology-use mediation and communities of practice to develop interventions to promote adoption and integration of EHRs into chronic care management processes in these practice settings. The field results suggest that developing community-based knowledge and resources to assist physician organizations one-on-one may be essential for their effective utilization of EHRs.
The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.
OBJECTIVE: To examine primary care physicians’ perceptions of how disease management programs affect their practices, their relationships with their patients, and overall patient care.
DESIGN: Cross-sectional mailed survey.
SETTING: The 13 largest urban counties in California.
PARTICIPANTS: General internists, general pediatricians, and family physicians.
MEASUREMENTS AND MAIN RESULTS: Physicians’ self-report of the effects of disease management programs on quality of patient care and their own practices. Respondents included 538 (76%) of 708 physicians: 183 (34%) internists, 199 (38%) family practitioners, and 156 (29%) pediatricians. Disease management programs were available to 285 (53%) physicians; 178 had direct experience with the programs. Three quarters of the 178 physicians believed that disease management programs increased the overall quality of patient care and the quality of care for the targeted disease. Eighty-seven percent continued to provide primary care for their patients in these programs, and 70% reported participating in major patient care decisions. Ninety-one percent reported that the programs had no effect on their income, decreased (38%) or had no effect (48%) on their workload, and increased (48%) their practice satisfaction.
CONCLUSIONS: Practicing primary care physicians have generally favorable perceptions of the effect of voluntary, primary care-inclusive, disease management programs on their patients and on their own practice satisfaction.
An estimated 99 million Americans live with a chronic illness. Meeting the needs of this population is one of the major challenges facing the U.S. health care system today and in the future. Dozens of studies, surveys, and audits have revealed that sizable proportions of chronically ill patients have not received effective therapy and do not have optimal disease control. The consistent findings of generally substandard care for many chronic conditions have spurred proposals that care be shifted to specialists or disease management programs. Published evidence to date does not indicate any clear superiority of these alternatives to primary care. The defining features of primary care (that is, continuity, coordination, and comprehensiveness) are well suited to care of chronic illness. A rapidly growing body of health services research points to the design of the care system, not the specialty of the physician, as the primary determinant of chronic care quality. The future of primary care in the United States may depend on its ability to successfully redesign care systems that can meet the needs of a growing population of chronically ill patients.
The treatment of chronic disease is often complicated by the coexistence of multiple medical conditions and by the presence of social and psychological impediments. The needs posed by patients with chronic disease are overwhelming the capacity of the American health care system. Alternative disease management systems that rely on specially trained nurse case managers to implement detailed clinical protocols, including drug algorithms, have shown efficacy in managing chronic medical conditions, singly and in combination. By fostering integration of care across subspecialty and medical-social boundaries, such systems enable treatment of the patient with disease(s), not simply treatment of disease(s) in the patient. Working closely with primary care physicians, often by telephone-mediated interaction with patients, nurse case managers may take an expanded role in meeting the challenges posed by chronic disease.
To investigate how health plans manage chronic diseases.
Health plan medical directors were surveyed regarding the disease management (DM) practices of their plans.
We took a stratified random sample of 65 plans, all members of the American Association of Health Plans. Forty-five plans responded. Results were weighted to be representative of the industry (including nonmember plans). Medical directors were asked to consider that they had a DM program only if 2 things were true: (1) A majority of a plan's enrollees could not be ineligible for a DM program for non-clinical reasons (eg, geographic location); and (2) a DM program had to have at least 6 of the 8 components of a DM program as defined by the Disease Management Association of America.
The 3 diseases most likely to be the focus of DM programs were diabetes, asthma, and congestive heart failure. For each of these diseases, at least one quarter of Americans were enrolled in plans offering a DM program. Medical directors perceived their DM programs to be highly effective in reducing mortality and morbidity and in improving the functional status of patients, and perceived them to be effective in lowering cost. The greatest challenge in implementing DM programs involves information technology. These results yield insights into the future of treatment of chronic disease in the United States.
Health plans have made a significant investment in programs to improve care for chronic illness. The almost universality of DM programs highlight the need for scholarly evaluations of their effectiveness and cost effectiveness.
The chronic care model is a guide to higher-quality chronic illness management within primary care. The model predicts that improvement in its 6 interrelated components-self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources-can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. Case studies are provided describing how components of the chronic care model have been implemented in the primary care practices of 4 health care organizations.
Background:
In 1997 Virginia Mason Health System (VMMC), a vertically integrated hospital and multispecialty group practice, had no process or system to deliver the right patient clinical data, in the right form, at the right place--when providers needed it for effective patient care. Without any new investment in technology, a work group of five individuals leveraged existing, primarily paper-based information systems to launch development and implementation of a provider prompting tool--a primary care and prevention (PCP) report--which prompted providers to complete screening, prevention, and disease management services at every patient appointment.
Planning and implementing the tool:
The work group developed and pilot tested the report and created a mechanism by which the report could be delivered just in time before each patient's appointment. The report integrated information from independent appointment scheduling, laboratory results reporting, patient demographics, and billing data sources. MEASURING THE PCP REPORT'S IMPACT: The results of two separate analyses demonstrate improvement in rates of screening and prevention across VMMC soon after the PCP report became available. These results led senior leadership to make the PCP report's utilization a systemwide imperative.
Discussion:
The PCP report is used by nearly all primary care providers as a prompt to complete screening, prevention, and disease management services at every patient appointment.
Disease management (DM) has become a widely accepted way to support care delivery in the chronically ill patient population. Patients enrolled in these programs have been shown to have better health, fewer complications and comorbidities, and lower health care costs. The development of advanced information management technologies is further enhancing the role DM plays in optimizing outcomes and cost-effectiveness in clinical care. These emerging information management technologies (EIMT) include advances in software, hardware, and networking, all of which share common impact attributes in their ability to improve cost-effectiveness of care, quality of care, and access to care. Specific examples include interactive websites with the ability to engage patients in the self-care management process, the embedding of biometric devices (digital scales, modem-enabled glucose meters in the home, blood pressure monitoring, etc.), workflow and care coordination programs that add intelligence via guideline-directed alerts and reminders to the delivery process, registries that include a summary of personal health data that can be used as a reference point for improved clinical decisions, and the systematic collection of aggregated, de-identified clinical, administrative, and cost data into comprehensive data sets to which predictive modeling analytic tools can be applied. By way of case example, we also present data from a controlled clinical trial utilizing EIMT in the form of home-based weight measurement using a digital scale and linkage to a care coordination center for the management of severe congestive heart failure. Outcome results on 85,515 patient-months of an aggregate commercial and Medicare continuously enrolled population demonstrated an average reduction of care utilization (hospitalization) of 57% and a reduction in related delivery cost (per member per year payments) of 55%. We conclude that EIMT have already begun to offer significant and quantifiable benefits to DM and are likely to become heavily embedded in care management strategies in the future.
Payment incentives as a part of physicians' compensation are commonplace but have been aimed predominantly at restricting expensive services. A novel concept is the payment of physicians for providing high-quality care, on the basis of explicit measures of quality. Such a system has recently been adopted in the United Kingdom. The authors believe that the idea is worth pursuing, but they point out important impediments and challenges to its successful implementation.
Rapid adoption of disease management has outpaced systematic evaluation of its net value in improving health outcomes and mitigating healthcare cost. This article identifies areas in which outcomes research in disease management is needed to demonstrate its value or to enhance its performance. Patient identification for disease management relies on administrative database queries but the trade-offs in sensitivity, specificity, and predictive value of alternative queries are not well known. Large-scale deployment, rapid patient engagement, and repeated interactions between patients and nurses could be important attributes for attaining measurable improvements in quality and cost reduction over short periods of time, but these hypothesis need to be tested. There is a trend toward integration of multiple chronic disease management programs onto a single platform. To support this trend, there is a need for a corresponding set of integrated clinical guidelines or "meta-guidelines" that combine the contents of individual practice guidelines. The relative contribution of various disease management interventions in improving clinical results, lowering costs, and their respective ease of implementation is not known. Research leading to a better understanding of tradeoffs could lead to more rational resource allocation and better overall outcomes. Coordination between disease management programs and physician practices is lacking. Research aimed at defining operational and technical interfaces and cultural and behavioral professional adjustments necessary to achieve integration and coordination is needed. The lack of a consistent analytical framework for evaluating clinical and financial outcomes has made comparisons of reported results impossible and has rendered many reports unreliable. Theoretical work on a standard methodology that integrates clinical and financial outcomes and empiric validation is needed.
In health care settings, individuals from different disciplines come together to care for patients. Although these groups of health care personnel are generally called teams, they need to earn true team status by demonstrating teamwork. Developing health care teams requires attention to 2 central questions: who is on the team and how do team members work together? This article chiefly focuses on the second question. Cohesive health care teams have 5 key characteristics: clear goals with measurable outcomes, clinical and administrative systems, division of labor, training of all team members, and effective communication. Two organizations are described that demonstrate these components: a private primary care practice in Bangor, Me, and Kaiser Permanente's Georgia region primary care sites. Research on patient care teams suggests that teams with greater cohesiveness are associated with better clinical outcome measures and higher patient satisfaction. In addition, medical settings in which physicians and nonphysician professionals work together as teams can demonstrate improved patient outcomes. A number of barriers to team formation exist, chiefly related to the challenges of human relationships and personalities. Taking small steps toward team development may improve the work environment in primary care practices.
Managed care introduced disease management as a replacement strategy to utilization management. The focus changed from influencing treatment decisions to supporting self-care and compliance. Disease management rendered operational many elements of the chronic care model, but it did so outside the delivery system, thus escaping the financial limitations, cultural barriers, and inertia inherent in effecting radical change from within. Medical management "after managed care" should include the functional and structural integration of disease management with primary care clinics. Such integration would supply the infrastructure that primary care physicians need to coordinate the care of chronically ill patients more effectively.
Strategies to reduce health expenditures through the improvement of health and quality of care are in high demand. A group of experts formed a nonpartisan, independent work group, under the sponsorship of the National Managed Health Care Congress. Its goal was to establish a list of easy-to-understand, actionable, and usable recommendations to enable disease management program advocates to conduct basic-level evaluations.
The work group made recommendations concerning identification of reference and intervention population, population definitions, quantitative methods and data quality, confounding and bias, and stakeholder agreements/contracting.
A case study was created to quantitatively illustrate some of the major issues raised by the work group. Five typical errors were simulated by applying different rules to the intervention population than to the reference population: differential inclusion (high versus low risk), differential exclusion (high versus low risk) and differential claims run-out. Compared with the true impact, four of the five errors resulted in a bias toward "intervention effect," while one (differential inclusion of high-risk patients) was biased against the "intervention effect." The direction and magnitude of the bias in natural settings will not necessarily follow this pattern.
Heart failure (HF) remains a major public health problem that affects 5 million patients in the United States.1 HF is the leading cause of hospitalization for people 65 years of age and older, and rates of hospital readmission within 6 months range from 25% to 50%.1,2 The personal burden of HF includes debilitating symptoms, frequent rehospitalizations, and high rates of mortality.2 HF also poses a substantial economic burden, with annual direct costs for the care of HF patients estimated to be between $20 billion and $56 billion.1–3 A number of studies have documented marked variation in the quality of care judged by specific performance measures and substantial underuse of evidence-based, guideline-recommended HF therapies in patients receiving conventional care.2,4,5 Moreover, patient behavioral factors (such as nonadherence to diet and medications) and economic and social factors frequently contribute to rehospitalizations.2,5,6 The traditional model of care delivery is thought to contribute to frequent hospitalizations because in these brief episodic encounters, little attention may be paid to the common modifiable factors that precipitate many hospitalizations.6 As such, there has been much interest in identifying effective methods to improve the quality of care for HF patients while reducing costs.
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We and others first studied the use of comprehensive HF management programs involving specialty care and a multidisciplinary team; the goals of the HF disease management (DM) programs included optimization of drug therapy, intensive patient education, vigilant follow-up with early recognition of problems, and identification and management of patients’ comorbidities.7–9 HF patients who were cared for in these programs were shown to have significantly fewer rehospitalizations, lower healthcare costs, improved functional and symptom status, and better quality of life as compared either with their preintervention status or with HF patients being treated with conventional care. …
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