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A Multilevel Model of Care for Chronic Disease Management

A Review


In a previously posted blog, the idea of health and chronic disease management was explored. But what is chronic disease? How big of a problem is it? And how do healthcare providers and teams manage chronic disease(s)? There have been a number of frameworks created and reviewed over the years but we are going to explore one in particular that has been lauded as the framework that has been implemented by a large number of organizations globally.


What is Chronic Disease?

Chronic disease, or non-communicable disease (NCD), is defined as:

  • Lasting one (1) year or longer and,

  • require ongoing medical attention, or

  • limit activities of daily living, or both (CDC, 2020).

Globally, the World Health Organization (WHO) estimates that NCD contributes to almost 70% of deaths (WHO, 2020). In Canada, 67% of deaths are attributed to one of the four most commons NCD’s:

  • Cancer

  • Diabetes

  • Cardiovascular disease

  • Chronic respiratory disease (Public Health Agency of Canada, 2013).

According to the Centers for Disease Control and Prevention (2020), the major risk factors that contribute to NCD include:

  • Tobacco use

  • Poor nutrition

  • Lack of physical activity

  • Excessive alcohol use

NCD causes a strain on the healthcare system. It is imperative that evidence-based frameworks and strategies are utilized in order to promote health and manage NCD (Barr et al., 2003).



Chronic Care Model (CCM)

Developed in the mid-1990s by Dr. Ed Wagner and the staff at the MacColl Center for Health Care Innovations, the CCM “responded to the need for the healthcare system to change structurally how it addressed the needs of patients with chronic illness” (Boehmer et al., 2018, p. 1). The CCM “identifies the essential elements of a health care system that encourage high-quality chronic disease care” (Improving Chronic Illness Care, 2011). The model essentially shifted primary cares’ focus to one that supports proactive management of NCD with a framework that encourages productive interactions between informed, activated patients, and the prepared, proactive healthcare provider(s).

The model identifies 6 core areas that encourage high-quality chronic disease management. The 6 areas include (in no particular order):

  1. Organization of Health Care

  2. Self-Management Support

  3. Delivery System Design

  4. Decision Support

  5. Clinical Information Systems

  6. The Community/Resources and Policies (Improving Chronic Illness Care, 2011).


Research has shown that utilizing all 6 parts of the framework leads to the best possible patient outcomes but it is not necessary to implement them all at once; a graduated approach across the health care continuum can occur (Tillman, 2020).

CCM at a Glance

Let’s review what each of the 6 core elements of the CCM means (Improving Chronic Illness Care, 2011; Institute for Healthcare Improvement, 2020; Tillman, 2020).


1. Organization of Health Care

  • Create a culture, organization, and mechanisms that promote safe, high-quality care

  • Continuous quality improvement related to chronic and preventative disease management (i.e. policies, procedures, financial planning)

2. Self-Management Support

  • Empower and prepare patients to manage their health and health care

  • Providing basic information about their disease

  • Utilize supportive strategies

  • Organize resources in order to provide ongoing support

3. Delivery System Design

  • Assure the delivery of effective, efficient clinical care and self-management support

  • Healthcare providers roles and responsibilities are defined but allow for cross-training to provide care and continuity

  • Goals are patient-centered

  • Standardized patient follow up and case management as required

  • Use of evidence-based care

4. Decision Support

  • Promote clinical care that is consistent with scientific evidence and patient preferences

  • Best practice and evidence-based guidelines drive the day-to-day practices in order to provide high-quality patient care

  • Ongoing education to healthcare providers

5. Clinical Information Systems

  • Organize patient and population data to facilitate efficient and effective care

  • Monitoring of metrics and performance data

  • Share information with patients and healthcare providers

6. Community

  • Mobilize community resources to meet the needs of patients

  • Encourage patients to participate in community programs

  • Healthcare teams forming partnerships with community resources

CCM as a Pathway to New and Improved Models

The CCM has been the cornerstone in the improvement of care delivery for chronically ill people. Even with the recent analysis that its impact on chronic disease management may be more limited than initially thought, the framework has provided the foundation for new and improved models (Timpel et al., 2020). One of those models is the Integrated Care Model.

One of the NCD’s that follow the Integrated Care Model framework is chronic obstructive pulmonary (COPD). COPD is frequently seen in acute and primary care settings and global incidence is on the rise. As a healthcare provider working on an acute medical unit, patients with a diagnosis of COPD is something that we frequently encounter and are required to assist in managing. In an upcoming blog post I will be exploring the connection between the Integrated Care Model and how COPD is managed across the healthcare continuum.

References:

Barr, V.J., Robinson, S., Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D., & Salivaras, S. (2003). The expanded chronic care model: An integration of concepts and strategies from population health promotion and chronic care model. Healthcare Quarterly, 7(1), 73-82. http://www.longwoods.com/content/16763


Boehmer, K. R., Abu Dabrh, A. M., Gionfriddo, M.R., Erwin, P., & Montori, V.M. (2018). Does the chronic care model meet the emerging needs of people living with multimorbidity? A systemic review and thematic synthesis. PLoS ONE, 13(2), 1-17. http://0-search.ebscohost.com.aupac.lib.athabascau.ca/login.aspx?direct=true&db=a9h&AN=127877277&site=eds-live


Canadian Broadcasting Corporation. (2013). Our killer lifestyle: Infographic. https://www.cbc.ca/liverightnow/tips-and-articles/getting-started/non-communicable-diseases-who.html


Centers for Disease Control and Prevention. (2020). About chronic diseases. https://www.cdc.gov/chronicdisease/about/index.htm


Improving Chronic Illness Care. (2011). The chronic care model. http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2


Institute for Healthcare Improvement. (2020). Changes to improved chronic care. http://www.ihi.org/resources/Pages/Changes/ChangestoImproveChronicCare.aspx



Tillman, P. (2020). Applying the chronic care model in a free clinic. The Journal for Nurse Practitioners, 16(8), e117-e121. https://linkinghub.elsevier.com/retrieve/pii/S1555415520303020


Timpel, P., Lang, C., Wens, J., Contel, J.C., & Schwarz, P.E.H. (2020). The manage care model – Developing an evidence-based and expert-driven chronic care management model for patients with diabetes. International Journal of Integrated Care, 20(2), 1-13. http://www.ijic.org/article/10.5334/ijic.4646/


World Health Organization. (2020). Noncommunicable diseases. https://www.who.int/health-topics/noncommunicable-diseases#tab=tab_1

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