The Chronic Care Model

A chronic illness is long-term. It is an illness that lasts for more than three months. A chronic illness is persistent and generally can’t be prevented by vaccination or cured by medication. Dealing with a chronic illness is very stressful and may change a person’s daily living. Some examples of chronic diseases include heart disease, cancer, type 2 diabetes, stroke, chronic respiratory problems and obesity. According to the CDC, in 2012 about 117 million people had one or more chronic health conditions. And that’s only about half of all adults! Seven of the top ten causes of death in 2010 were chronic illness. Both heart disease and cancer accounted for nearly 48% of all deaths. The World Organization of Health stated that eighty percent
For about twenty years, GHRI scientists have created better models of care and are widely recognized for the Chronic Care Model. The effectiveness of care for major chronic illness has improved by progress in clinical and behavioral interventions. But there are still many patients who are not advancing. What could be the reason for this? The Institute of Medicine reported that there is an increase on medical care from the rapid increase of chronic disease and complexity of science and technology and inability of the system to meet these demands because of poorly organized system and poor knowledge in modern technology. Our care systems are so use to responding to acute illnesses and the immediate problem. While the patent was rather accepting, there was little urgency to develop self-management skills or tracking programs. According to the IOM, if the fundamental problem is the design of the system, then improvements in care “cannot be
They succeeded because they used one or more of the following; provider-oriented components such as continuing education or physician feedback, organizational changes in staff or management of visits and follow-up, information systems changes, and patient-oriented interventions of an educational or supportive nature. The Cochrane review team concluded that the interventions focus shouldn't just be on the provider's behavior but on the patient's. The Chronic Care Model consists of six elements: health care organization, community resources, self management support, delivery system design, decision support, and clinical information system. Improvement must begin with the Senior leader of the health system. Promoting the chronic disease improvement project and improvement strategies would encourage the senior leader’s involvement and support. Providing financial and non-financial incentives based on quality of care would mean the information given to the patient would be more impactful then the time spent with a patient. The emphasis of the organization's goals and business plan are also important because they keep the team structured and focused. Community resources could be anything from schools, the government, non-profit organizations, or peer-support groups. Patients are encouraged to join programs to develop new relationships. Joining other health care organizations could enhance continuity of care or fill in the gap in needed services.