Case 6: Innovations in the care for chronically ill persons
Learning goals:
1. What is the impact of chronic disease on the healthcare system?
Fragmented care:
- Different physicians
Healthcare system level?
2. Why should chronic care be improved?
Old model not sufficient enough: healing, fragmented care ect.
New model:
3. What are the different innovative care models concerning chronic care? (Focus on
disease management and integrated care) (Chronic care model is from last year).
a. Strengths and weaknesses of the model
4. How is integration defined?
a. What types of integration?
5. What is the triple and quadruple aim?
a. Why was it changed?
6. How can policy makers manage?
Literature suggestions:
First 3 learning goals: Nolte
Learning goal 4: Singer
Learning goal 5: two independent articles
Learning goal 6: Raus
Nolte E, Knai C, Saltman RB (eds). Assessing chronic disease management in European
health systems. Concepts and approaches. Copenhagen, Denmark: European Observatory
on Health Systems and Policies; 2014.
- Chapter 1: Introduction (page 1-7)
As populations age and advances in health care allow those with once fatal conditions to
survive, the prevalence of chronic conditions is rising in many countries. Although the rising
burden of chronic disease is driven, in part, by population ageing it is important to recognize
that such conditions are not limited to the older population. Thus, increasing numbers of
children and young people are developing some form of chronic health problem.
In high-income countries, mental disorders, musculoskeletal disorders, chronic obstructive
pulmonary disease (COPD) or asthma, and diabetes, are among the leading causes of
chronic disability.
Chronic diseases pose a sizeable burden for national economies, with associated costs
estimated at up to 7% of a country’s gross domestic product.
,The goals of care for those with chronic conditions are not to cure but to enhance functional
status, minimize distressing symptoms, prolong life through secondary prevention and
enhance the quality of life.
1.2.1 Conceptualizing chronic disease and chronic disease management
- Acute conditions are potentially curable within a short period of time.
- Chronic conditions are either incurable or require prolonged treatment and care,
and for which there is a chance of developing intercurrent episodes or acute illnesses
associated with the chronic condition
We defined disease management as comprising the following components:
(1) an integrated approach to care or coordination of care among providers, including
physicians, hospitals, laboratories and pharmacies;
(2) patient education; and
(3) monitoring or collecting patients’ outcome data for the early detection of potential
complications
Box 1.1 Approaches to chronic disease management or chronic care: definition of terms
- Care pathway(s) (synonyms: clinical pathway; care map; integrated care pathway):
Task-oriented care plan(s) that specify essential steps in the care of patients with a
specific clinical problem and describe the patient’s expected clinical course.
- Case management: Intensive monitoring of a person with complex needs by a
named case manager – usually a (specialist) nurse – through the development of
care or treatment plans that are tailored to the needs of the individual patient who is
at high risk socially, financially and medically.
- Chronic care model (CCM): A conceptual framework that presents a structure for
organizing health care comprising of four key components:
o (1) self-management support;
o (2) delivery system design;
o (3) decision support; and
o (4) clinical information systems.
- Coordinated care (synonyms: care management): Development and implementation
of a therapeutic plan designed to integrate the efforts of medical and social service
providers, often involving designated individuals to manage provider collaboration.
, - Disease management (programme) (DMP): Definitions of disease management
(programmes) vary substantially. Common features are:
o (1) an integrated approach to care/coordination of care among providers,
including physicians, hospitals, laboratories and pharmacies;
o (2) patient education; and
o (3) monitoring/collecting patient outcomes data for the early detection of
potential complications.
DM programmes do not normally involve general coordination of care. They also not
normally include preventive services such as flu vaccination.
- Integrated care: Types of collaboration, partnerships or networks between providers
of health and social care services that work together to meet the multidimensional
needs of an individual patient/client or a category of persons with similar needs/
problems.
- Managed discharge: Arrangements for the transfer of an individual from hospital to
an appropriate setting (primary care; community care) to ensure that any
rehabilitation, recuperation and continuing health and social care needs are
identified and met.
- Multidisciplinary team(s)/care: An “extension” of case management that also
normally involves the development of treatment plans tailored to the medical,
psychosocial and financial needs of patients. Its key feature is the use of a broader
range of medical and social support personnel (including physicians, nurses,
pharmacists, dietitians, social workers and others) to facilitate transition from
inpatient acute care to long-term, outpatient management of chronic illness.
- Nurse-led clinic: A formalized and structured health care delivery arrangement in
which a nurse with advanced competence to practise in a specific health care area
(nurse practitioner, clinical nurse specialist, specialist nurse) acts as the first point of
contact of care. The nurse manages patients either independently or
interdependently with other members of a health care team in at least 80% of their
work. The key interventions are: nursing therapeutics, encompassing assessment
and evaluation; health teaching/counselling; treatment and procedures; and case
management. (NB: Nurse-led clinics are different from nurse-led care insofar as the
former describe a formalized and structured delivery arrangement, whereas the
latter also includes other arrangements, for example, case management, liaison
nurses, discharge nurse, etc.).
- Provider network(s): A group of providers bringing together different levels of care
(for example, health and social care or primary and secondary care).
- Chapter 2: What we know: a review of the evidence base on approaches to caring
for people with chronic conditions (page 9-21). Sufficient to focus on conclusions.
2.1 Managing care for people with chronic conditions: concepts and definitions
Disease management, by definition, traditionally targets patient groups with specific
conditions, such as diabetes.
Integrated care is typically aimed more broadly at people with complex needs that arise
from multiple chronic conditions, coupled with increasing frailty at old age.
2.1.1 Disease management
Learning goals:
1. What is the impact of chronic disease on the healthcare system?
Fragmented care:
- Different physicians
Healthcare system level?
2. Why should chronic care be improved?
Old model not sufficient enough: healing, fragmented care ect.
New model:
3. What are the different innovative care models concerning chronic care? (Focus on
disease management and integrated care) (Chronic care model is from last year).
a. Strengths and weaknesses of the model
4. How is integration defined?
a. What types of integration?
5. What is the triple and quadruple aim?
a. Why was it changed?
6. How can policy makers manage?
Literature suggestions:
First 3 learning goals: Nolte
Learning goal 4: Singer
Learning goal 5: two independent articles
Learning goal 6: Raus
Nolte E, Knai C, Saltman RB (eds). Assessing chronic disease management in European
health systems. Concepts and approaches. Copenhagen, Denmark: European Observatory
on Health Systems and Policies; 2014.
- Chapter 1: Introduction (page 1-7)
As populations age and advances in health care allow those with once fatal conditions to
survive, the prevalence of chronic conditions is rising in many countries. Although the rising
burden of chronic disease is driven, in part, by population ageing it is important to recognize
that such conditions are not limited to the older population. Thus, increasing numbers of
children and young people are developing some form of chronic health problem.
In high-income countries, mental disorders, musculoskeletal disorders, chronic obstructive
pulmonary disease (COPD) or asthma, and diabetes, are among the leading causes of
chronic disability.
Chronic diseases pose a sizeable burden for national economies, with associated costs
estimated at up to 7% of a country’s gross domestic product.
,The goals of care for those with chronic conditions are not to cure but to enhance functional
status, minimize distressing symptoms, prolong life through secondary prevention and
enhance the quality of life.
1.2.1 Conceptualizing chronic disease and chronic disease management
- Acute conditions are potentially curable within a short period of time.
- Chronic conditions are either incurable or require prolonged treatment and care,
and for which there is a chance of developing intercurrent episodes or acute illnesses
associated with the chronic condition
We defined disease management as comprising the following components:
(1) an integrated approach to care or coordination of care among providers, including
physicians, hospitals, laboratories and pharmacies;
(2) patient education; and
(3) monitoring or collecting patients’ outcome data for the early detection of potential
complications
Box 1.1 Approaches to chronic disease management or chronic care: definition of terms
- Care pathway(s) (synonyms: clinical pathway; care map; integrated care pathway):
Task-oriented care plan(s) that specify essential steps in the care of patients with a
specific clinical problem and describe the patient’s expected clinical course.
- Case management: Intensive monitoring of a person with complex needs by a
named case manager – usually a (specialist) nurse – through the development of
care or treatment plans that are tailored to the needs of the individual patient who is
at high risk socially, financially and medically.
- Chronic care model (CCM): A conceptual framework that presents a structure for
organizing health care comprising of four key components:
o (1) self-management support;
o (2) delivery system design;
o (3) decision support; and
o (4) clinical information systems.
- Coordinated care (synonyms: care management): Development and implementation
of a therapeutic plan designed to integrate the efforts of medical and social service
providers, often involving designated individuals to manage provider collaboration.
, - Disease management (programme) (DMP): Definitions of disease management
(programmes) vary substantially. Common features are:
o (1) an integrated approach to care/coordination of care among providers,
including physicians, hospitals, laboratories and pharmacies;
o (2) patient education; and
o (3) monitoring/collecting patient outcomes data for the early detection of
potential complications.
DM programmes do not normally involve general coordination of care. They also not
normally include preventive services such as flu vaccination.
- Integrated care: Types of collaboration, partnerships or networks between providers
of health and social care services that work together to meet the multidimensional
needs of an individual patient/client or a category of persons with similar needs/
problems.
- Managed discharge: Arrangements for the transfer of an individual from hospital to
an appropriate setting (primary care; community care) to ensure that any
rehabilitation, recuperation and continuing health and social care needs are
identified and met.
- Multidisciplinary team(s)/care: An “extension” of case management that also
normally involves the development of treatment plans tailored to the medical,
psychosocial and financial needs of patients. Its key feature is the use of a broader
range of medical and social support personnel (including physicians, nurses,
pharmacists, dietitians, social workers and others) to facilitate transition from
inpatient acute care to long-term, outpatient management of chronic illness.
- Nurse-led clinic: A formalized and structured health care delivery arrangement in
which a nurse with advanced competence to practise in a specific health care area
(nurse practitioner, clinical nurse specialist, specialist nurse) acts as the first point of
contact of care. The nurse manages patients either independently or
interdependently with other members of a health care team in at least 80% of their
work. The key interventions are: nursing therapeutics, encompassing assessment
and evaluation; health teaching/counselling; treatment and procedures; and case
management. (NB: Nurse-led clinics are different from nurse-led care insofar as the
former describe a formalized and structured delivery arrangement, whereas the
latter also includes other arrangements, for example, case management, liaison
nurses, discharge nurse, etc.).
- Provider network(s): A group of providers bringing together different levels of care
(for example, health and social care or primary and secondary care).
- Chapter 2: What we know: a review of the evidence base on approaches to caring
for people with chronic conditions (page 9-21). Sufficient to focus on conclusions.
2.1 Managing care for people with chronic conditions: concepts and definitions
Disease management, by definition, traditionally targets patient groups with specific
conditions, such as diabetes.
Integrated care is typically aimed more broadly at people with complex needs that arise
from multiple chronic conditions, coupled with increasing frailty at old age.
2.1.1 Disease management
