Chronic illness is illness that continues indefinitely, limits activity, and requires ongoing activities and response from patients and caregivers (Larsen, 2009; Robert Wood Johnson Foundation, Partnership for Solutions, 2002). It is a relatively new phenomenon. In the early 1900s, the leading causes of mortality in the U.S. were tuberculosis, pneumonia, and gastritis/enteritis. The average life expectancy then was 47 years (National Center for Health Statistics, 1909). Health care was an oxymoron as diagnosis and treatment of disease were the only tools in the health care armamentarium. With only a rudimentary comprehension of the major causes of mortality and without antibiotics, insulin, and imaging ability, the sick were identified late in their illness (or not at all) and either got better or died. The care of the day was illness care. The system that was developed to handle disease was based on face-to-face encounters with physicians who provided a service in exchange for a fee. That fee-for-service system with an emphasis on illness management remains central to health care policy today.

A century later, life expectancy is 78.9 years (Social Security Online Actuarial Tables, 2010) and the first baby boomers are Medicare-eligible, challenging the nation’s ability to effectively and efficiently manage the growing prevalence of chronic illness. Seven out of 10 deaths among Americans each year are a result of chronic disease (CDC, 2009). The most common chronic diseases in the U.S. are hypertension, chronic mental conditions, respiratory diseases, arthritis, eye disorders, asthma, cholesterol disorders, and diabetes. Among children, eye disorders, emotional/behavioral disorders, asthma, and other respiratory diseases account for the top four chronic problems (CDC & the Merck Company Foundation, 2007). One quarter of people with chronic conditions have activity limitation (Agency for Health Care Quality and Research, 1998).

Eighty percent of the causes of chronic illness are lifestyle-related and thus preventable. DeVol and colleagues (2007) estimate that if the health care system targeted prevention, the economic impact of chronic disease could be reduced by 27%. The CDC identifies preventable causes of chronic disease as: lack of physical activity, poor nutrition, tobacco use, and alcohol consumption. All of these are modifiable and with appropriate health counseling can prevent the majority of chronic disease (Robert Wood Johnson Foundation, 2002). Treatment of chronic disease accounts for more than 75% of the nation’s health care budget. The financial impact on the U.S. economy of treatment and lost productivity caused by chronic illness is more than $1.3 trillion per year, with projections of an increase to $5.7 trillion by 2050 (Centers for Medicare and Medicaid Services, 2008). Lowering obesity rates alone would avoid $60 billion in treatment expenses (CDC, 2009; Dall, et al., 2010). While the majority of people with a chronic disease are under 65 years of age, the likelihood of having more than one chronic disease increases with age; 83% of all Medicare beneficiaries report at least one chronic condition (Anderson, 2005), and 23% of Medicare beneficiaries with five or more conditions account for 68% of the program’s funding (DeVol et al., 2007).

Increases in health care spending have not translated into improvements in health care quality. In a fee-for-service episodic care model, research shows that care is fragmented and illness-based; patients frequently do not get the care that they want or need (Coleman, Austin, Brach, & Wagner, 2009; Mattke, Seid, & Ma, 2007). Neither federal entitlement programs nor private insurances have provided coverage for prevention or care management.

Periodically, efforts have been made to manage cost and sporadically test models of care management. The earliest effort at cost control emerged in 1980 with the implementation of a prospective payment system utilizing diagnosis-related groups (DRGs). This shift from payment for any service consumed to regulated payment for specific diagnoses appears to have somewhat curbed Medicare spending, however prospective payment is rooted in an illness model and does not address disease management (Coulam & Gaumer, 1991).

In the early 1990s, Wagner determined that an orientation to acute episodic illness and lack of a system to educate patients regarding self management were barriers to quality chronic disease management. He developed the Chronic Care Model (CCM) and outlined the elements essential to high-quality chronic illness management (Wagner, 1998). The Robert Wood Johnson Foundation authorized a comprehensive evaluation of the CCM in the Improving Chronic Illness Care initiative and demonstrated that implementing the model in primary care practices improves chronic care outcomes (Nutting et al., 2009; Bodenheimer, Wagner, & Grumbach, 2002). However, reimbursement has been based on an episodic illness model.

In March, 2010, President Barack Obama signed HR 3590, The Affordable Care Act (ACA). This first major change in health care finance and delivery provides the seeds for overhauling the existing system, developing evidence-based models of prevention and chronic care provision, and testing a reimbursement infrastructure that will support health care for the majority of Americans.

The initiative that has gained the most traction in blending quality and reimbursement has been the development of the Patient-Centered Medical Home. The concept of the “medical home” was first advanced by the American Academy of Pediatrics (AAP) in 1967 as a place where all medical information about a patient would be located (Sia, Tonniges, Osterhus, & Taba, 2004). The concept has since expanded and is defined as “a health care setting that provides patients with timely, well-organized care and enhanced access to providers” (Beal, Doty, Hernandez, Shea, & Davis, 2007, p. ix) and must be “patient centered.” Gerteis and colleagues (2003) identified eight dimensions of patient-centered care (Box 29-1). Central to the success of a medical home is whole-person orientation and the relationship between a regular, accessible provider and an informed patient or family caregiver.

Building on the AAP concept of the Medical Home, the American College of Physicians (ACP) proposed the development of the “advanced medical home,” a care delivery model that would not only provide for a location of patient records, but also provide patient-centered care based on the principles of the Chronic Care Model and include reimbursement incentives for the management and coordination of care (Barr & Ginsburg, 2006). The advanced medical home model requires that a physician, most often a primary care physician, lead a team of health care professionals. The key attributes of the advanced medical home are listed in Box 29-2. Reimbursement in this model would support system-based versus volume-based care; that is, payment based on a process of care delivery that assures positive outcomes rather than the volume of patients seen by a given provider. As well, reimbursement would acknowledge the value of providing coordinated care in a system that incorporates the elements of the CCM. In order to qualify as an advanced medical home, a practice would be required to be meet the National Committee for Quality Assurance (NCQA) guidelines for a medical home. The NCQA’s 9 standards (with 10 “must pass” elements) are listed in Box 29-3.

BOX 29-2

Key Elements of the Advanced Medical Home

1. Use evidence-based medicine and clinical decision support tools to guide decision-making at the point of care.

2. Organize the delivery of that care according to the Chronic Care Model, but leverage the core functions of the CCM to provide enhanced care for all patients with or without a chronic condition.

3. Create an integrated, coherent plan for ongoing medical care in partnership with patients and their families.

4. Provide enhanced and convenient access to care not only through face-to-face visits but also via telephone, e-mail, and other modes of communication.

5. Identify and measure key quality indicators to demonstrate continuous improvement in health status indicators

6. Adopt and implement the use of health information technology to promote quality of care, to establish a safe environment in which to receive care, to protect the security of health information, and to promote the provision of health information exchange.

7. Participate in programs that provide feedback and guidance on the overall performance of the practice and its physicians.

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