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Chronic Illness
Care
At the heart of effective
chronic illness care are productive interactions between patients
and their care teams. Such interaction includes:
- An assessment of
clinical status
- Routine evaluation
of patient needs
- The application
of effective treatments
- Development of a
comprehensive care plan
- Ongoing self-management
support, and
- Active follow-up
over time.
Chronic Care Model
The Chronic Care Model
(Figure 1) is an attempt to synthesize
available evidence of system changes that improve care for chronic
illness, relevant to arthritis and other conditions causing symptoms
and disability (Wagner
et al, 1996a; 1996b;
1999;
2000).
It was based on a survey of best practices, expert opinion, more
promising interventions in the literature, and quality improvement
work on diabetes, depression, and cardiovascular disease (Wagner
et al., 1999).
Figure 1 shows how
system changes in the six areas of the Chronic Care Model influence
interactions between patients and providers to produce better
care and improved outcomes.
Figure
5.1 The Chronic Care Model
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There are three overarching
themes in the Chronic Care Model:
- It
is population-based,
meaning that care is planned and organized for all arthritis
patients in the practice, whether they present for care or not.
Standardized assessment and follow-up, for example, are routinely
provided for all arthritic patients in a given system, rather
than for select high-risk patients. Clinical information systems
that include key information on all patients with arthritis
facilitate population surveillance and reminders of needed services.
This population-based approach differs from usual care, where
providers respond to whatever is scheduled for that day.
- It is evidence-based
in that clinical management is based on the best randomized
studies.
- It
is patient-centered;
that is, the patient's concerns are a priority in the practice
and a central feature of improvement efforts. Enhanced collaboration
between patients and providers leads to improved patient outcomes,
including better symptom control. Collaborative management of
chronic illness involves setting goals and developing a care
plan with patients, training and support for self-management,
and active follow-up to monitor success and modify care (Von
Korff et al., 1997). These elements of care are essential
in a condition like arthritis, where outcomes depend on keeping
patients active and motivated over the long run to care for
their condition.
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