Complex adaptive chronic care

Background The Chronic Care Model (CCM) is widely taken up as the universal operational framework for redesigning health systems to address the increasing chronic disease burden of an ageing population. Chronic care encompasses health promotion, prevention, self management, disease control, treatment and palliation to address ‘chronicity’ of long journeys through disease, illness and care in the varying contexts of complex health systems. Yet at an operational level, CCM activities are predominantly based on an evidence‐base of discreet chronic disease interventions in specific settings; and their demonstrable impact is limited to processes of select disease management such as diabetes in specific disease management programs. Aims This paper proposes a framework that makes sense of the nature of chronicity and its multiple dimensions beyond disease and argues for a set of building blocks and leverage points that should constitute the starting points for ‘redesign’? Findings Complex Adaptive Chronic Care is proposed as an idea for an explanatory and implementation framework for addressing chronicity in existing and future chronic care models. Chronicity is overtly conceptualized to encompass the phenomena of an individual journey, with simple and complicated, complex and chaotic phases, through long term asymptomatic disease to bodily dysfunction and illness, located in family and communities. Chronicity encompasses trajectories of self‐care and health care, as health, illness and disease co‐exist and co‐evolve in the setting of primary care, local care networks and at times institutions. A systems approach to individuals in their multi‐layered networks making sense of and optimizing experiences of their chronic illness would build on core values and agency around a local vision of health, empowerment of individuals and adaptive leadership, and it responds in line with the local values inherent in the community's disease‐based knowledge and the local service's history and dynamics. Complex Adaptive Chronic Care exceeds the current notions of disease management as an endpoint. Primary care team members are system adaptors in partnership with individuals constructing their care and system leadership in response to chronic illness, and enable healthy resilience as well as personal healing and support. Outcomes of complex adaptive chronic care are the emergence of health in individuals and communities through adaptability, self‐organization and empowerment. Discussion Chronic care reform from within a complex adaptive system framework is bottom up and emergent and stands in stark contrast to (but has to co‐exist with) the prevailing protocol based disease care rewarding selective surrogate indicators of disease control. Frameworks such as the Chronic Care Model provide guidance, but do not replace individual experience, local adaptive leadership and responsiveness. The awareness of complexity means opening up problems to a different reality demanding different set of questions and approaches to answer them.     

Continuity of care and quality care outcomes for people experiencing chronic conditions: A literature review

Continuity of patient care is frequently linked to quality care outcomes. The purpose of this paper is to examine the clinical trial literature in order to determine the extent to which informational, management, and relational continuity of care are associated with quality care indicators. A MEDLINE search of the literature via PubMed was conducted for clinical trials that were carried out from 1 January 1996-1 June 2005. Analyses of 32 unduplicated citations revealed a focus on one or more aspects of continuity and its association with quality care outcomes. Management continuity interventions were identified most often, followed by informational and relational continuity interventions. The outcomes were primarily patient-focused with a wide range of functional status, quality of life, and patient satisfaction indicators. This analysis provides implications for research that could contribute to an understanding of the types of continuity of patient care and their relationships to quality care.     

The significance of a collaborative practice model in delivering care to chronically ill patients: A case study of managing diabetes mellitus in a primary health care center

Non-communicable diseases, especially diabetes mellitus type two (DM2) constitute major health problems in Lebanon that have an adverse impact on health and health resources. Collaborative practice interventions may improve quality care of DM2 and reduce or delay complications. The purpose of this paper was to evaluate the impact of collaborative practice on the quality and cost of effective care for diabetic patients in a primary health care center. A chart audit review of 375 diabetic patients attending an inner city health center in Beirut (Lebanon) was conducted after three and a half years of collaborative practice intervention, which included guidelines for an interdisciplinary health team. Evaluation of the impact of collaborative practice was conducted on the process and outcome of care. The results indicated a high level of enthusiasm, support and the development of team spirit at the process level. At the outcome level there was improvement in documentation, increase in patient recruitment, increase in continuity of care, improvement of glycemic control and decreased cost. In conclusion collaborative practice interventions improved process and outcome variables for diabetic patients. It is suggested that this model could be developed for use in the care of other chronic diseases.     

End of life care: a discursive analysis of specialist palliative care nursing

AIM: The aim of this paper is to consider alternative approaches to service delivery for patients with chronic life-limiting illnesses other than cancer. It will also discuss the issues that arise when considering specialist palliative care services within a broader public health context in the United Kingdom. BACKGROUND: Contemporary specialist palliative care in the United Kingdom can be said to have two main client groups: the majority are people with a diagnosis of cancer, and a minority are those with a number of other chronic illnesses. From the evidence to date, patients dying from chronic, non-malignant disease experience a considerable number of unmet needs in terms of symptom control and psychosocial support. Although debates in the literature over the last decade have challenged the focus of specialist palliative care services on patients with a cancer diagnosis, only a minority of those with other chronic illnesses receive specialist palliative care services. DISCUSSION: Current models of specialist palliative care may not be the most appropriate for addressing the complex problems experienced by the many patients with a non-cancer diagnosis. We suggest that care should be structured around patient problems, viewing specialist palliative care as a service for those with complex end of life symptoms or problems. A role for innovative nurse-led care is proposed. CONCLUSION: Reframing the approach to specialist palliative care in the United Kingdom will require great effort on the part of all health and social care professionals, not least nurses. Critical and creative thinking are prerequisites to the development of new models of working. We suggest that a more coherent approach to research and education is required, in particular strategies that explore how patients and nurses can work together in exploring experiences of illness in order to develop more proactive approaches to care.     

Attending to the lightness of numbers: toward the understanding of critical care epidemiology

Most of the epidemiological studies in critical care do not express their results in terms of population burden of critical illness. This happens because the population at risk of critical illness is particularly difficult to estimate, once intensive care units (ICUs) receive patients from many sources. The study by Laupland in this issue of Critical Care provides a good estimate of the incidence of admission to ICUs in the Calgary Health Region. He considered the Calgary Health Region population as the denominator and explored the effects of a changing numerator according to the residency status (resident in Calgary or not) on the estimation of the burden of admission to the ICU. He demonstrated that if the residency status were not known, the incidence of admission to the ICU would have been overestimated by more than 50%. Furthermore, non-residents had a lower mortality despite higher Acute Physiology and Chronic Health Evaluation (APACHE) II and Therapeutic Intervention Scoring System (TISS) scores. There is tremendous variability in decisions to admit a patient to the ICU and the epidemiology of critical care is influenced by them in a subtle but inextricable way. An understanding of the population epidemiology of critical illness and the use of the ICU, the variations in these parameters, and factors that influence this variation is extremely important. The notable effect of a changing numerator on the estimation of the population burden of ICU admissions in the study by Laupland illustrates how fluid our estimates of disease incidence and mortality - the mainstays of epidemiology - can be.     

Caring for uninsured patients with diabetes: designing and evaluating a novel chronic care model for diabetes care

Background Safety net urban hospitals are being overwhelmed by an increasing number of patients with diabetes, who frequently only access the health system through visits to emergency departments and urgent care clinics. It is uncertain whether the chronic care model advocated for diabetes care would be feasible and effective for managing diabetes in an acute care setting. Objective Determine if redesigning the system of care for treating diabetic patients who do not have primary care doctors is feasible, acceptable to patients and effectively lowers patients' haemoglobin A1c, blood pressure and cholesterol levels. Design Prospective single cohort study. Patients A total of 1098 consecutive diabetic patients presenting to an urgent care clinic at an urban safety net public hospital in Chicago between October 2004 and April 2006 who had a haemoglobin A1c measured at baseline. Intervention Adapt the chronic care model for managing diabetes to the acute care setting of an urgent care clinic to manage uninsured patients with diabetes who do not have primary care. Results Among the 1098 patients, 833 (76%) had a repeat A1c during the 2‐ to 12‐month follow‐up period. On average, A1c values decreased by 1.5 percentage points; systolic blood pressure decreased by 9 mmHg; low‐density lipoprotein cholesterol decreased 11 points; and weight decreased 2.3 pounds (all: P < 0.001). The percentage using angiotensin‐converting enzyme inhibitor drugs increased from 45% to 83%; aspirin use increased from 38% to 83%; and statin use increased from 34% to 76%. Conclusions This novel chronic care model for diabetes care of uninsured patients without primary care doctors was feasible, acceptable and effective in increasing the quality of diabetes care and decreasing haemoglobin A1c, blood pressure, cholesterol and weight.     

Motivational interviewing-based health coaching as a chronic care intervention

Objective  To evaluate the impact of motivational interviewing-based health coaching on a chronically ill group of participants compared with non-participants. Specifically, measures that could be directly attributed to a health coaching intervention on chronic illness were assessed.
Design  Quasi-experimental study design.
Setting  A large medical university in the north-west United States.
Methods  One hundred and six chronically ill programme participants completed a health risk survey instrument prior to enrolment and again at approximately 8 months. Outcomes were compared with 230 chronically ill non-participants who completed the survey twice over a similar time frame. Inverse probability of treatment weights were used in conjunction with the propensity score to correct for selection bias.
Results  Compared with non-participants, programme participants improved their self-efficacy ( P  = 0.01), patient activation ( P  = 0.02), lifestyle change score ( P  = 0.01) and perceived health status ( P  = 0.03). Fewer participants increased their stages of change risk over time than non-participants ( P  < 0.01), and more participants decreased their stages of change risk over time than non-participants ( P  = 0.03).
Conclusion  These results support motivational interviewing-based health coaching as an effective chronic care management intervention in impacting outcome measures that could also serve well as a proxy in the absence of other clinical or cost indices.     

Community nurses and chronic disease in Israel: Professional dominance as a social justice issue

Chronic diseases are major causes of health inequalities. Community nurses can potentially make large contributions to chronic illness prevention and management in Israel but may be obstructed by professional dominance of physicians. However, insufficient research exists about community nursing in Israel, and how it may differ from other countries. This study aims to document chronic disease‐related community nursing roles in Israel, identify changes and trends in community nursing roles that may increase social justice, and understand how the roles and trends in community health nursing in Israel may differ from developments in other countries. In‐depth interviews were performed with 55 Israeli health system professionals, and 692 nurse care‐givers were asked open‐ended questions. Interview answers were analyzed to find themes and trends. The study found that community nurse roles in Israel have expanded, especially for chronic disease control. Commonalities exist with countries such as the United States and the UK, albeit with important differences. However, continued conflicts with physicians exist, which can limit nurses' contributions to reducing health inequalities. Community nurses' importance is growing. Enabling them to overcome professional dominance and improve chronic disease control can help reduce health inequalities in Israel and elsewhere.