Integrated Disease Management
Innovative Care for Chronic Conditions: Organizing and Delivering High Quality Care for Chronic Noncommunicable Diseases in the Americas
Care for chronic noncommunicable diseases (CNCDs) such as cardiovascular disease (CVD), diabetes, cancer, and chronic obstructive pulmonary disease (COPD) is a global problem. Research demonstrates that the vast majority of people with CNCDs do not receive appropriate care.
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This report describes a model of health care that could deliver integrated management of NCDs within the context of primary health care (PHC), and provides practical guidance for health care program managers, policy-makers, and stakeholders on how to plan and deliver high-quality services for people with CNCDs or CNCD risk factors. Key implications of integrated management at the policy level are also discussed, including the financial and legislative aspects of care and human resource development. The report includes a list of examples of effective intervention for each component of the Chronic Care Model. Furthermore, unpublished country based examples of the implementation of good practices in chronic care are showcased throughout the document.
The document concludes that the Chronic Care Model should be implemented in its entirety since its components have synergistic effects, where the whole is greater than the sum of the parts. Policy reforms and universal access to care are critical elements leading to better outcomes and reducing disparities in chronic disease care. It is critical to integrate PHC-based chronic care into existing services and programs. Chronic diseases should not be considered in isolation but rather as one part of the health status of the individual, who may be susceptible to many other health risks. A patient-centered care system benefits all patients, regardless of their health conditions or whether his/her condition is communicable or noncommunicable.
A care system based on the Chronic Care Model is better care for all, not only for those with chronic conditions. Primary care has a central role to play as a coordination hub, but must be complemented by more specialized and intensive care settings, such as diagnostic labs, specialty care clinics, hospitals, and rehabilitation centers. Finally the ten recommendations for the improvement of quality of care for chronic conditions are:
- Implement the Chronic Care Model in its entirety.
- Ensure a patient centered approach.
- Create (or review existing) multisectoral policies for CNCD management including universal access to care, aligning payment systems to support best practice.
- Create (or improve existing) clinical information system including monitoring, evaluation and quality improvement strategies as integral parts of the health system.
- Introduce systematic patient self-management support.
- Orient care toward preventive and population care, reinforced by health promotion strategies and community participation.
- Change (or maintain) health system structures to better support CNCD management and control.
- Create PHC-led networks of care supporting continuity of care.
- Reorient health services creating a chronic care culture including evidence-based proactive care and quality improvement strategies.
- Reconfigure health workers into multidisciplinary teams, ensuring continuous training in CNCD management.
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- The Chronic Care Model
- Self-Management Support
- Delivery System Design
- Decision Support
- Clinical Information System
- Health Care Organization
- Community Resources and Policies