Case 6: Innovations in the care for chronically ill persons
One of the greatest challenges facing healthcare systems in the 21st century is the increasing burden
of chronic disease. Greater longevity and ‘modernization’ of lifestyles, with increasing exposure to
many chronic disease factors, have combined to change the nature of conditions confronting health
systems. Besides being leading causes of death and disability worldwide, chronic conditions are
associated with tremendous medical costs and increasingly pressure existing healthcare budgets.
Although there are different definitions, the common theme is that chronic conditions require “a
complex response over an extended time period that involves coordinated inputs from a wide range
of health professionals and access to essential medicines and monitoring systems, all of which need
to be optimally embedded within a system that promotes patient empowerment”. Yet, healthcare is
still largely built around an acute, episodic model of care. As a result, conditions frequently go
untreated or are poorly controlled until more serious and acute complications arise. Even when
chronic disease is recognized, there is often a large gap between evidence-based treatment
guidelines and actual practice. Moreover, there is a lack of support for patients’ self-management,
which is often considered the most important element of high-quality chronic care, services are
fragmented, and follow-up is limited, to name but a few deficiencies.
In response, several countries are experimenting with new models of care delivery that can better
meet the complex needs of chronically ill patients. Perhaps best known from an international
perspective are disease management and the Chronic Care Model, both of which were first
introduced in the US and are based on the assumption that increasing the quality of chronic care
provision will result in improved health outcomes and, ultimately, in reduced costs. Although
(elements of) these innovative care strategies quickly spread to other countries, they have not been
embraced universally and are often subject of considerable criticism. There is general consensus,
however, that tackling the increasing societal and economic burden of chronic disease will require
nothing less than a transformation of existing healthcare systems. In recent years, the so-called
‘Triple Aim’ is gaining more and more attention internationally, and disruptive innovations in pursuit
of this new concept are being implemented in many countries worldwide.
Practical application (to be discussed during the post-discussion of case 6)
An often-heard critique on the disease management model is that it entails a highly standardized
approach to chronic care, which is centered on single diseases rather than patients’ actual health
needs. To quote James Hereford, the executive vice president of Group Practice (26 Medical Centers
in Washington and North Idaho): “We should never look at a patient as ‘that diabetic’ – we need to
optimize the care of that individual. Most patients are co-morbid. So, the cardiovascular patient is
often the same person as the diabetic. We need to optimize around that patient, not around a single
disease.”
Hereford describes this conceptual shift as mass customization, a concept that we discussed earlier in
this course (in Case 5). He believes mass customization is more important for high-value chronic care
than thinking about populations with particular conditions. While relatively new to the healthcare
sector, mass customization has long been a core production strategy in industry. It has been defined
by Davis as “the production of personalized or custom-tailored goods to meet consumers’ diverse
and changing needs at near mass production prices”. Thus, on the production spectrum, it lies
somewhere between mass production (i.e. pure standardization) and custom-made (i.e. pure
customization).
Below is a table that includes the three production approaches described above, i.e. pure
standardization, mass-customization, and pure customization. One cell has already been filled in: it
mentions disease management programs as an example of a purely standardized service in chronic
care. Please complete the rest of the cells in the table with examples of goods or services produced
in: (a) chronic care; and (b) other sectors (i.e. industry).
, Pure standardization Mass customization Pure customization
(i.e. mass-production) (i.e. made-to-order, (i.e.
built-to-order) custom-made/person
alized)
Good/service Disease management Population health Integrated care (n=1)
provided in chronic programs management
care
Good/service Kia Picanto Specific model of Kia Specific model of Kia
produced in other Picanto Picanto with extra
sector (industry) attributes
Background
The ‘tsunami of chronic conditions’
What is the definition of chronic disease?
Chronic disease: disease which has a long duration and a slow progression (WHO, 2018); tend to be
of long duration and are the result of a combination of genetic, physiological, environmental and
behavioral factors
Two important elements
- Long duration (at least 3 months)
- Slow progression (become worse and worse over time)
Definition of chronic conditions
- Chronic conditions: which are either incurable or require prolonged treatment and care and
for which there is a chance of developing intercurrent episodes or acute illness associated
with the chronic condition (Nolte, 2014)
Typology of chronic disease
Based on nature and course of disease (categories don’t exclude each other)
- Life threatening: diseases with a high risk of mortality (e.g. cancer)
- Intermittent: diseases that can relatively have a longer stable period (e.g. asthma)
- Progressively debilitating: diseases that have worse and worse consequences over time (e.g.
dementia, diabetes)
- Chronic mental illness: long term mental illness (e.g. depression, dementia)
Chronic disease tsunami (reasons for more chronic diseases)
- Population ageing
One of the greatest challenges facing healthcare systems in the 21st century is the increasing burden
of chronic disease. Greater longevity and ‘modernization’ of lifestyles, with increasing exposure to
many chronic disease factors, have combined to change the nature of conditions confronting health
systems. Besides being leading causes of death and disability worldwide, chronic conditions are
associated with tremendous medical costs and increasingly pressure existing healthcare budgets.
Although there are different definitions, the common theme is that chronic conditions require “a
complex response over an extended time period that involves coordinated inputs from a wide range
of health professionals and access to essential medicines and monitoring systems, all of which need
to be optimally embedded within a system that promotes patient empowerment”. Yet, healthcare is
still largely built around an acute, episodic model of care. As a result, conditions frequently go
untreated or are poorly controlled until more serious and acute complications arise. Even when
chronic disease is recognized, there is often a large gap between evidence-based treatment
guidelines and actual practice. Moreover, there is a lack of support for patients’ self-management,
which is often considered the most important element of high-quality chronic care, services are
fragmented, and follow-up is limited, to name but a few deficiencies.
In response, several countries are experimenting with new models of care delivery that can better
meet the complex needs of chronically ill patients. Perhaps best known from an international
perspective are disease management and the Chronic Care Model, both of which were first
introduced in the US and are based on the assumption that increasing the quality of chronic care
provision will result in improved health outcomes and, ultimately, in reduced costs. Although
(elements of) these innovative care strategies quickly spread to other countries, they have not been
embraced universally and are often subject of considerable criticism. There is general consensus,
however, that tackling the increasing societal and economic burden of chronic disease will require
nothing less than a transformation of existing healthcare systems. In recent years, the so-called
‘Triple Aim’ is gaining more and more attention internationally, and disruptive innovations in pursuit
of this new concept are being implemented in many countries worldwide.
Practical application (to be discussed during the post-discussion of case 6)
An often-heard critique on the disease management model is that it entails a highly standardized
approach to chronic care, which is centered on single diseases rather than patients’ actual health
needs. To quote James Hereford, the executive vice president of Group Practice (26 Medical Centers
in Washington and North Idaho): “We should never look at a patient as ‘that diabetic’ – we need to
optimize the care of that individual. Most patients are co-morbid. So, the cardiovascular patient is
often the same person as the diabetic. We need to optimize around that patient, not around a single
disease.”
Hereford describes this conceptual shift as mass customization, a concept that we discussed earlier in
this course (in Case 5). He believes mass customization is more important for high-value chronic care
than thinking about populations with particular conditions. While relatively new to the healthcare
sector, mass customization has long been a core production strategy in industry. It has been defined
by Davis as “the production of personalized or custom-tailored goods to meet consumers’ diverse
and changing needs at near mass production prices”. Thus, on the production spectrum, it lies
somewhere between mass production (i.e. pure standardization) and custom-made (i.e. pure
customization).
Below is a table that includes the three production approaches described above, i.e. pure
standardization, mass-customization, and pure customization. One cell has already been filled in: it
mentions disease management programs as an example of a purely standardized service in chronic
care. Please complete the rest of the cells in the table with examples of goods or services produced
in: (a) chronic care; and (b) other sectors (i.e. industry).
, Pure standardization Mass customization Pure customization
(i.e. mass-production) (i.e. made-to-order, (i.e.
built-to-order) custom-made/person
alized)
Good/service Disease management Population health Integrated care (n=1)
provided in chronic programs management
care
Good/service Kia Picanto Specific model of Kia Specific model of Kia
produced in other Picanto Picanto with extra
sector (industry) attributes
Background
The ‘tsunami of chronic conditions’
What is the definition of chronic disease?
Chronic disease: disease which has a long duration and a slow progression (WHO, 2018); tend to be
of long duration and are the result of a combination of genetic, physiological, environmental and
behavioral factors
Two important elements
- Long duration (at least 3 months)
- Slow progression (become worse and worse over time)
Definition of chronic conditions
- Chronic conditions: which are either incurable or require prolonged treatment and care and
for which there is a chance of developing intercurrent episodes or acute illness associated
with the chronic condition (Nolte, 2014)
Typology of chronic disease
Based on nature and course of disease (categories don’t exclude each other)
- Life threatening: diseases with a high risk of mortality (e.g. cancer)
- Intermittent: diseases that can relatively have a longer stable period (e.g. asthma)
- Progressively debilitating: diseases that have worse and worse consequences over time (e.g.
dementia, diabetes)
- Chronic mental illness: long term mental illness (e.g. depression, dementia)
Chronic disease tsunami (reasons for more chronic diseases)
- Population ageing
