MARKET 1 Lecture Notes - Lecture 12: American Medical Association, Chronic Care Management, Chronic Care
Innovation and Quality Management – HPI4002
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Case 6 – What is the best healthcare system for the
chronically ill patients
Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health and cost. Health Affairs, 2008;27(3):759-69.
Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high performing primary
care. Annals of Family Medicine, 2014;12(2):166-171.
Nolte E, Knai C, Saltman RB (eds). (2014). Assessing chronic disease management in European health systems.
Concepts and approaches. Chapter 1 & 2
Bodenheimer T, Wagner EH, Grumbach K. (2002) Improving primary care for patients with chronic illness. Journal
of the American Medical Association, 288 (14), 1775-9.
Table of Contents
1 Chronic disease ....................................................................................................................... 2
1.1 Burden of chronic diseases ............................................................................................... 2
1.2 Problems/ gaps in treatment ............................................................................................. 3
2 Models of Care Delivery for the chronically ill ...................................................................... 3
2.1 Chronic Care Model ......................................................................................................... 4
2.2 6 essential elements of Chronic Care Model .................................................................... 5
2.2.1 Disease Management ................................................................................................ 7
2.2.2 Integrated Care .......................................................................................................... 7
2.3 Triple Aim ........................................................................................................................ 8
2.4 Population Health Management ....................................................................................... 9
3 10 building blocks of High-Performing Primary Care ........................................................... 9
1. Definition of chronic disease.
2. What is the burden of chronic diseases?
3. What are problems and gaps within the treatments of chronic diseases?
4. What are the models of care delivery for the chronically ill?
a. Chronic Care Model
b. Triple Aim Model
5. Explain the strengths and weaknesses of each model.
Innovation and Quality Management – HPI4002
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1 Chronic disease
WHO definition
Noncommunicable diseases (NCDs), also known as chronic diseases, tend to be of long duration
and are the result of a combination of genetic, physiological, environmental and behaviors
factors.
Nolte (2014)
Acute conditions – are potentially
curable within a short period of time.
Chronic conditions – either incurable
or require prolonged treatment of care.
There is a chance of developing acute
illness associated with chronic
conditions.
1.1 Burden of chronic diseases
Nolte (2014)
Individual:
• (health) burden
• Need to adhere to treatment regimes
• The goals for those with chronic conditions are not to cure but to enhance functional status,
minimize distressing symptoms, prolonging life through secondary prevention and enhance
quality of life.
o These goals are unlikely accomplished through the traditional acute, episodic
model of care, which tends to see the patient as passive recipient of care and where
treatment aims at return to normal.
▪ Especially, where people have multiple health problems, creating a range of
diverse and sometimes contradictory needs, the conventional care model is
insufficient.
Society:
• High economic burden of costs associated with health care use, medication and other
interventions
• Reduced productivity at work
• Responding to the burden of chronic disease presents challenges for all health systems.
The prevalence of chronic conditions is rising in not only older people but also younger
people.
Innovation and Quality Management – HPI4002
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Health care system:
• Increased complexity of care
• Focus on prevention of chronic conditions
• Providing services that meet the requirements caused by chronic health problems
• 71% worldwide – leading cause of death.
• Chronic diseases pose a burden for national economies, with associated costs estimated at
up to 7% of a country’s gross domestic product.
o Societal costs arise partly as a result of direct health care costs (e.g. health care use,
medication, and interventions), with additional indirect costs (e.g. increased
absenteeism, and reduced productivity at work).
• These challenges add to the complexity facing health systems, which require effective
measures to prevent disease through reducing the major chronic disease risk factors and
addressing influences that drive exposure, while also providing services to meet the
requirement caused by chronic health problems, thereby ensuring that people with
established disease can participate in society.
1.2 Problems/ gaps in treatment
Reactive & proactive
Conventional model is insufficient
A range of health professionals are needed, with patient-centeredness in mind.
In chronic conditions, a long term relationship with the patient is more important.
2 Models of Care Delivery for the chronically ill
Several models and strategies have been developed to improve care for people with chronic
conditions:
• Disease management
• Integrated care
• Chronic care model
• Triple aim
• Population health management
• The 10 building blocks
The goal is to move from a disease specific management to a population health management
(triple aim).
Document Summary
Case 6 what is the best healthcare system for the chronically ill patients. Bodenheimer t, ghorob a, willard-grace r, grumbach k. the 10 building blocks of high performing primary care. Nolte e, knai c, saltman rb (eds). (2014). Assessing chronic disease management in european health systems. Bodenheimer t, wagner eh, grumbach k. (2002) improving primary care for patients with chronic illness. 2 models of care delivery for the chronically ill 3. 6 essential elements of chronic care model 5. 10 building blocks of high-performing primary care 9. Noncommunicable diseases (ncds), also known as chronic diseases, tend to be of long duration and are the result of a combination of genetic, physiological, environmental and behaviors factors. Acute conditions are potentially curable within a short period of time. Chronic conditions either incurable or require prolonged treatment of care. There is a chance of developing acute illness associated with chronic conditions.
