Case 6: Innovations in the care for chronically ill persons
Learning goals:
1. Define chronic conditions/diseases.
2. What is the problem with treating chronically ill patients?
a. What is the impact for patients and for the healthcare system (costs, etc.)?
b. What is the deficiency of current healthcare system?
3. What are the different models to meet the needs of chronically ill persons? (disease
management, triple aim, chronic care model) & What are the strengths and
weaknesses?
1. Define chronic conditions/ diseases
There are a lot of different definitions. The most simple and straightforward definition is
from the WHO. That definition is based on two elements:
- Long duration: at least three months
- Progressiveness over time: chronic diseases tend to be progressive over time the
disease is getting worse. This can be either a slow (most often) or a fast process.
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.
Classification of chronic disease
Based on nature and course of disease. One category does not exclude the other.
- Life threating
- Intermittent
Some chronic diseases such as asthma are moving from stable to a severe period to
stable again.
- Progressively debilitating
- Chronic mental illness
, Classification of chronic disease
Based on impact on patient and their families:
- Disease onset
- Disease course
- Disease outcome
o Is the disease fatal or is a long-life still possible?
- Degree of incapacitation
o Does it lead to functional and/or cognitive limitations?
Chronic diseases can be controlled, but not be cured.
The relation between chronic care and chronic illness
- Chronic care refers to the medical care which addresses a pre-existing or long-term
illness;
- Chronic illness is a human health condition or disease that is persistent or otherwise
long- lasting in its effects or a disease that comes with time.
So chronic illness needs to be managed by chronic care.
Learning goals:
1. Define chronic conditions/diseases.
2. What is the problem with treating chronically ill patients?
a. What is the impact for patients and for the healthcare system (costs, etc.)?
b. What is the deficiency of current healthcare system?
3. What are the different models to meet the needs of chronically ill persons? (disease
management, triple aim, chronic care model) & What are the strengths and
weaknesses?
1. Define chronic conditions/ diseases
There are a lot of different definitions. The most simple and straightforward definition is
from the WHO. That definition is based on two elements:
- Long duration: at least three months
- Progressiveness over time: chronic diseases tend to be progressive over time the
disease is getting worse. This can be either a slow (most often) or a fast process.
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.
Classification of chronic disease
Based on nature and course of disease. One category does not exclude the other.
- Life threating
- Intermittent
Some chronic diseases such as asthma are moving from stable to a severe period to
stable again.
- Progressively debilitating
- Chronic mental illness
, Classification of chronic disease
Based on impact on patient and their families:
- Disease onset
- Disease course
- Disease outcome
o Is the disease fatal or is a long-life still possible?
- Degree of incapacitation
o Does it lead to functional and/or cognitive limitations?
Chronic diseases can be controlled, but not be cured.
The relation between chronic care and chronic illness
- Chronic care refers to the medical care which addresses a pre-existing or long-term
illness;
- Chronic illness is a human health condition or disease that is persistent or otherwise
long- lasting in its effects or a disease that comes with time.
So chronic illness needs to be managed by chronic care.
