Chronic Disease Management

Over the last few years, it has become unimaginable to talk about chronic disease management without at least one slide showing the Wagner model, describing how the aforementioned productive interactions improve outcomes. What are we talking about?

We’re talking about care teams. The teams could come in all shapes and sizes, but they share interdisciplinary collaboration as a defining feature. We’re also talking about finally recognizing that the effective management of the chronic conditions that drive most health care cost has to be more than the customary series of discrete episodes of acute care that we have designed our health care systems around. We’re talking about fundamental changes to health care delivery system design and to our expectations. We’re talking about primary care providers as the focal point of care, working in partnership with specialized services and with community resources and we’re talking about using information systems to bind the various community and clinical team members to common evidence-driven plans or protocols -- modified to meet the needs of individual patients. Finally, we’re talking about empowering patients and their families to take an active and vital role in the management of their own care.

I have been invited to participate in this innovative dialogue on the impact of chronic illness on the Canadian healthcare system. The premise of this dialogue is that there has been insufficient attention focused on the biggest health care challenge facing the 21st century. It is my view that the issue is getting plenty of attention, but it requires such profound and fundamental change in assumptions, attitudes,and system organization that it has been difficult over the last 10 years to move from rhetoric to the kind of change we need.the farther upstream we assemble the team and get them working together on a plan, the better the outcomes.

Most proponents of the chronic care model speak of the power to reduce morbidity and mortality on a large scale (with the attendant cost savings this would imply) by re-inventing how diabetes is managed. If people with diabetes work with their family physicians, nurses, dietitians and other health professionals on an evidence-based plan based on both the patient’s specific health goals and an active role for the patient in learning, monitoring, and managing, then downstream savings will be enormous. If diabetes is better managed, heart disease, blindness, and a host of other expensive health conditions may be averted. Clearly, the farther upstream we assemble the team and get them working together on a plan, the better the outcomes – start before obesity, start before unhealthy diet becomes habitual, and success is both more likely and more “profitable.

Approximately 500,000 Canadians have dementia, the most significant cause of disability among seniors and a disease that costs Canadian society many billions of dollars per year. After a decade of talking about how we can save the health care system by applying the chronic care model to the management of diabetes, it’s time we looked at broadening the model’s applicability. Approximately 500,000 Canadians have dementia, the most significant cause of disability among seniors and a disease that costs Canadian society many billions of dollars per year. The disease is deadly and can cause enormous grief and devastation over many years, since families are often involved in 24/7 vigilance and care. Incidence and impact of Alzheimer’s disease and other kinds of dementia is highly correlated with age.

We are all acutely aware of the phenomenon of the aging boomers, the first of whom will be turning 65 in three years. Dementia affects one out of every 50 individuals between 65 and 74 years of age, and the risk rises to 1 in 9 for individuals between 75 and 84 and 1 in 3 for people over 85. In the absence of a national dementia strategy, including widespread adoption of the chronic care model, dementia may well overwhelm the Canadian health care system.

Dementia appears to be highly amenable to the core principles of chronic disease management. With the earlier diagnoses we have seen in recent years, patients and their families are in a good position to take on the task of self-management – learning about the disease, the risk mitigation opportunities, intervention choices, and coping mechanisms. The disease is highly amenable to the concepts of patient/family self-management and teams developing and taking action on an evidence-based plan, with roles identified for family physicians and other members of the primary care component of the team, specialized experts (psychiatrists, geriatricians, neurologists, neuropsychologists), community resources (Alzheimer Society staff and volunteers) and family caregivers – all pulling together and each playing their unique and interdependent roles.

The chronic care model uses the patient’s unique situation as the starting point and marshalls the unique competencies of the patient, family caregiver, family physician, nurse, social worker and other team members to help the patient achieve health goals by following a plan.

One of the key advantages of chronic care management and, especially, the interdisciplinary collaboration that is at the heart of the model is the diversity of perspectives essential to the identification and management of co-morbid conditions or complex chronic conditions. Managing diabetes, chronic heart disease or other major chronic conditions is tough enough without the further complication of dementia. Unfortunately, many of these conditions affect older people simultaneously. This fact underlies the strength of the model. When old people show up at their family physician’s office and see a sign on the wall advising them to tell the doctor about “one problem per visit,” where do they start? I’m old? I’m frail? I have diabetes but cannot monitor my diet because of my dementia? The chronic care model uses the patient’s unique situation as the starting point and marshalls the unique competencies of the patient, family caregiver, family physician, nurse, social worker and other team members to help the patient achieve health goals by following a plan. What a concept!