Applying the Chronic Care Model (Part 1)

1. Reading: Module 1 Recap (5 minutes)

To briefly recap what was covered in the previous module, Health systems encompass all institutions, individuals, and efforts primarily dedicated to enhancing health (WHO, 2000). They are designed to enhance people's health and well-being, meet expectations, and offer protection against health-related costs. Presently, healthcare systems face significant systemic challenges, including inadequate performance, access barriers, subpar quality, inefficient use, high costs, and low satisfaction. The primary chronic conditions causing premature mortality and disability are cardiovascular diseases (hypertension), cancers, and diabetes.

The major contributors to chronic diseases are unhealthy diet, physical inactivity, and tobacco use. According to a recent WHO report, eliminating these risk factors could prevent at least 80% of heart disease, stroke, and type 2 diabetes and over 40% of cancer (source: Preventing Chronic Diseases: a vital investment, 2005). WHO identifies four primary types of chronic diseases: cardiovascular diseases (e.g., heart attacks, stroke), cancer, chronic respiratory diseases (e.g., chronic obstructed pulmonary disease, asthma), and diabetes (Alwan, 2011). About 80% of chronic disease deaths occur in low- and middle-income countries.

Cardiovascular diseases are the leading cause of mortality in developing countries. In Jamaica, hypertension and diabetes are the top chronic disorders among the general population and significant risk factors for conditions such as cerebrovascular disease (stroke) and coronary heart disease. One in three Jamaicans has hypertension, one in eight is living with diabetes, and one in two is overweight or obese. Nearly 4 out of 5 individuals succumb to NCDs. The Chronic Care Model (CCM) serves as a pivotal framework for healthcare innovation.

This model identifies crucial elements of a healthcare system that promote high-quality care. It posits that favorable outcomes (clinical, satisfaction, cost, and function) stem from productive interactions. To facilitate such interactions, the system must develop four areas at the practice level (illustrated in the middle): self-management support (assisting patients in living with their conditions), delivery system design (defining the healthcare team and patient interactions), decision support (identifying optimal care and ensuring consistent implementation), and clinical information systems (capturing and utilizing critical clinical information). These aspects reside within a healthcare system, with broader organizational aspects influencing clinical care. The healthcare system exists within a larger community, where resources and policies also shape the care that can be provided. Notably, self-management support is positioned on the edge between the health system and the community, reflecting the visibility of patient-centric care. The Expanded CCM underscores health promotion for individuals and communities to prevent and manage chronic diseases, recognizing the role of social determinants of health in overall well-being.

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Sources:

Alwan A, Maclean DR, Riley LM, d'Espaignet ET, Mathers CD, Stevens GA, Bettcher D. Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries. Lancet. 2010 Nov 27;376(9755):1861-8. doi: 10.1016/S0140-6736(10)61853-3. Epub 2010 Nov 10. PMID: 21074258.

Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4.(The Chronic Care Model image first appeared in its current format in this article.)