The Chronic Care Model (Katherine Gibbs and Melanie Taylor) INTRODUCTION A large proportion of time spent by those working currently within the field of primary health care revolves around short consultations initiated by the client to discuss their immediate health issue. The Royal College of General Practitioners notes that the management of chronic disease is often fitted around this acute care ( while I am here can I have my diabetes script ) and it remains largely unsystematic. This episodic care may be of a high standard, but has rarely been planned to meet the longer term needs of patients with chronic illnesses. Chronic illness (also known as long term or life long conditions) is a significant health burden. It is estimated that in New Zealand approximately 70% of clients have one or more chronic illnesses. They are the leading cause of hospitalizations, use 70% of health funds, and account for 80% of all deaths (National Health Committee, 2005). Rapid aging of the population and the greater longevity of people with many chronic conditions (Wagner et al, 2001) mean optimal management of these individuals is becoming critical. Living with a chronic illness can be difficult. It takes a heavy toll on the physical and mental health of the individual and their supporting friends, family and workplaces. Receiving good care and learning how to self manage symptoms can maximise quality of life as well as lessen the impact on the health system. While there is, and presumably always will be, a need for sound, robust acute care, the paradigm shift required for the sustained and effective management of people with life long conditions is challenging. Calls for change have been coming from the highest level (Barr, Robinson, Marin-Link, Underhill, Dotts, Ravensdale, Silivaras,, 2003) and are increasingly heeded around the world. It is now understood that for effective and efficient management of chronic illness a change in systems is required (Wagner, Austin, Davis, Hindmarsh, Schaefer, Bonomi, 2001).
This article provides a brief overview of the Wagner chronic care model which MidCentral DHB is now looking to use as its framework of choice for developing systems to better manage care of people living with long term conditions. THE CHRONIC CARE MODEL Ed Wagner MD and his colleagues from America s MacColl Institute for Health Care Innovation developed the Chronic Care Model in the 1990 s after recognising that systems and processes based on an acute care model failed to meet the comprehensive needs of the client with a chronic illness. The Chronic Care Model proposed by Wagner offers a systematic approach to improving health delivery. The central role of the primary care team working in partnership with secondary care colleagues is emphasised. It aims to improve the quality of health outcomes for patients based on the philosophy that care can be delivered more effectively and efficiently if patients with chronic conditions take an active role in their own health and wellness. Concurrently, providers are also supported with the necessary resources and expertise to better assist these people in managing their condition/s. THE CHRONIC CARE MODEL Health System Community Self- Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Client Productive Interactions Prepared, Proactive Practice Team Improved outcomes In this model Wagner places an individual practice setting (such as a General Practice) within the Health System, which in turn is itself situated in the Community.
The other four elements within the Health System, namely Self Management Support, Delivery System Design, Decision Support and Clinical Information Systems are grouped together which suggests that quality improvement initiatives, when implemented, would effect care delivery for clients with chronic conditions. For practitioners working in General Practice, these four elements are where the greatest effort and attention should be placed, as influencing the wider health system and community iss problematic and beyond the scope of most individual health providers. Each element is now discussed in turn: * Community In essence this element requires those within the health system to form durable, useful partnerships with other organisations and entities within the wider community. This is important as the health system alone cannot fix or indeed influence the management of chronic conditions in isolation. Community organisations can assist the health system by advocating for polices to improve client care; develop interventions to fill gaps in current services, encourage their members to attend self management programmes and finally provide helpful resource material. * Health System This element emphasises the need to create a culture within the health system that promotes safe, high quality care chronic illness care. All members of the organisation need to be motivated and ready for change for this to occur. Proposed ways of improving care delivery include the promotion of multidisciplinary teamwork, alignment of incentives and improving care coordination across organisations. * Self Management Support This element recognises that merely telling the client what to do or handing them some material to read is not sufficient. True self management involves emphasising the patients central role in managing their health and illness - fostering a sense of responsibility for their own health. The practitioner is encouraged to use effective assessment tools and counselling techniques such as motivational interviewing or health coaching to explore behaviour change. Tools such as goal setting and individual care plans or health and wellness plans are used to assist the client to plan for the change. The practitioner may provide emotional support and further education at this time.
* Delivery System Design This element is all about effective teamwork having defined roles and delegated tasks among team members, organising practice around planned care, providing case management for complex patients and ensuring regular follow up of clients as a standard procedure. In essence it is about making sure each client gets they care they need. Health literacy (the patient s ability to understand health related information) and cultural competence are essential components of this element. * Decision Support This element challenges us to embed evidence based guidelines into our daily practice. Treatment decisions need to be based on explicit, proven guidelines supported by research, with the aim of ensuring that all clients receive the best possible care. The use of specialist expertise and effective teaching methods (for practitioners) are also key components of this element. * Clinical Information Systems The ability to share information with clients and providers to coordinate care is vital, as is the technology to track individuals, groups and whole populations. Utilising this type of software means it will be possible to identify relevant sections of the community for proactive care. Timely reminders will be useful to prompt guideline based care. Finally, monitoring and evaluation of care to individuals, groups and population will be possible. In effectively combining all of these elements this Model leads to planned Productive Interactions which over time assures the delivery of critical clinical and behavioural elements of care and which meet the need for patient-centredness. This aspect both assists the development of, and results from the creation of, informed activated clients and prepared proactive practice teams. Informed activated clients have the required knowledge, skill, confidence and motivation to make sound decisions so that they self manage their chronic condition effectively. Prepared, proactive practice teams are those which have the required client information, decision support, people, equipment and time to deliver evidence based clinical management and self management support.
The final component is Improved Outcomes. These extend beyond clinical indicators and include factors perceived as important to the client such as improved quality of life and functional outcomes. Cost and reduction of service usage could also be monitored. At MidCentral DHB we have started using the Wagner model as a framework to plan and develop services for clients with long term conditions. In future editions of this Journal we anticipate informing readers through use of this framework as to some of the innovations underway in our region. 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 the chronic care model. Hospital Quarterly, 7, 10, 73-82. National Health Committee (2005). People with chronic conditions: a discussion paper. Wellington: National Health Committee. Improving Chronic Illness Care (ICIC). Model Elements. http://www.improvingchroniccare.org/change/model/components.html retrieved 27.11.2006 Royal College of General Practitioners http://www.rnzcgp.org.nz/. retrieved 9.10.07. Wagner, E.H., Austin, B.T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic illness care: Translating evidence into action. Health Affairs, 20 (6), 64 78. This article was recently published in The Practice Nurse Magazine, Volume 7, Number 4 (June 2008).