5-2 Final Project Milestone Two Existing Initiative PDF

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HCM 340 5-2 Final Project Milestone Two: Existing Initiative Patients and healthcare providers have been struggling for many years to overcome gaps in coordinating care for chronic illnesses. Chronic illnesses are the leading cause of death and disability in the U.S. Six in ten adults in the U.S. have a chronic disease and four in ten adults have two or more chronic diseases. (National Center for Chronic Disease Prevention and Health Promotion, 2020). This population is vulnerable to adverse outcomes, their care generally results in high medical costs. Data from 2005 showed that more than 133 million people, or almost half of all Americans, live with a chronic condition. That number is projected to increase by more than one percent per year by 2030, resulting in an estimated population of 171 million requiring chronic disease management (Improving Chronic Illness Care, 2006). Concerns over how to best care for people with chronic illnesses have grown in recent years among both practitioners and policymakers. The Chronic Care Model initiative identifies six fundamental areas that form a system that encourages high-quality chronic disease management. Facilities must focus on these six areas, as well as develop productive interactions between patients that are proactive in their care and providers who have the necessary resources and expertise (Wagner, 1998). The six changes that will help address the gap in coordinating care for chronic illnesses consist of, selfmanagement support, delivery system design, decision support, clinical information systems, organization of health care, and community. The Chronic Care Model was published in its current form in 1998. It originated from a synthesis of scientific literature undertaken by The MacColl Institute for Healthcare Innovation in the early 1990’s. During a 9-month project funded by the Robert Wood Johnson Foundation, an early version of the Model underwent extensive

review by an advisory panel of experts and was then compared with the features of leading chronic illness management programs across the U.S. (Improving Chronic Illness Care, 2006). The delivery system is one of the most important aspects of overcoming the gap in coordinating care for chronic illnesses. In a well-designed delivery system, providers plan visits well in advance, based on the patient’s needs and self-management goals (Wagner, 1998). Patients with chronic illness need support and information, to be proactive of their own health care. This is self-management support. It is essential for patients to have the basic knowledge about their illness and ongoing support from friends and family, but most importantly from their healthcare providers and community. Community programs and organizations should support or expand patients’ health care. Decision support should be based on proven guidelines supported by at least one defining study (Wagner, 1998). Primary care providers should stay in the loop when their patient is referred to a specialist. A clinical information system should be implemented and used by the entire care team to track populations of patients as well as individual patients. This system will help track progress, course of treatment, and anticipate future problems. The entire organization of health care must be engaged in the improvement efforts in order to achieve any progress. Some reasons as to why this initiative may not be achieving the changes it’s intended for is due lack of patient compliance, patients inadequately being trained to manage their illness, lack of follow-ups from providers due to overwhelming cases, and rushed providers not following established guidelines. The only way to overcome these issues is the complete transformation of health care from a system that mainly responds when a person is sick instead of a system that is proactive and focused on keeping a person as healthy as possible (Improving Chronic Illness Care, 2006).

Healthcare providers are doing their best, but sometimes the facilities and healthcare delivery systems in which they work with make it difficult to provide good care and follow the initiative of the Chronic Care Model. By changing systems, we are closing that gap. Successful chronic care produces the types of clinical outcomes that patients expect, and that healthcare providers need to thrive financially. It is in everyone’s best interest for providers to adopt the Chronic Care Model and implement patient engagement strategies that lead to active partnerships with patients and better healthcare outcomes.

References

Improving Chronic Illness Care. (2006). Home. Retrieved November 25, 2020, from http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model National Center for Chronic Disease Prevention and Health Promotion. (2020, September 24). Chronic Diseases in America. Retrieved November 25, 2020, from https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm Wagner, Edward. “Changes to Improve Chronic Care: IHI.” Institute for Healthcare Improvement, 1998, www.ihi.org/resources/Pages/Changes/ChangestoImproveChronicCare.aspx....