Chronic Care Management - Chronic Care Models

Chronic Care Models

In the latter part of the 20th century, researchers began to develop care models for the assessment and treatment of the chronically ill.

Nurse researchers, such as S. Wellard, C. S. Burckhardt, C. Baker and P. N. Stern, and I. M. Lubkin and P. D. Larson, were often on the front lines of actual care for patients with ongoing treatments for conditions such as diabetes or renal failure. They stated that their patients experienced a trajectory of "phases," and that during some of these phases the patients responded quite differently to the same interventions.

Individuals who suffered from chronic illnesses, such as C. Register and S. Wells, have given detailed accounts of their experiences and made recommendations about how to manage chronic conditions. Associations proliferated for those with specific conditions (Sjögren's syndrome, chronic fatigue syndrome, peripheral neuropathy, etc.), and these groups have engaged in advocacy work, acted as clearinghouses for information, and began funding research.

Edward H. Wagner, M.D., Director of The MacColl Institute for Healthcare Innovation, Director of The Robert Wood Johnson Foundation national program "Improving Chronic Illness Care", and Senior Investigator at Group Health Research Institute in Seattle, WA developed the Chronic Care Model, or CCM. The CCM summarizes the basic elements for improving care in health systems on different levels. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. The Chronic Care Model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.

The Stanford Self-Management Program is a community-based self-management program that helps people with chronic illness gain self-confidence in their ability to control their symptoms and manage how their health problems will affect their lives.

Partnership for Solutions, a Johns Hopkins/Robert Wood Johnson collaborative, conducts research to improve the care and quality of life for individuals with chronic health conditions.

J. O. Prochaska and his colleagues, investigating issues associated with the treatment of addictions, have described a transtheoretical model of behavior change as a process rather than an event. They have advocated assessment and treatment based on the patient’s stage in the process.

Patricia Fennell, working on the experiences of imposed change (such as illness, grief, or trauma), has developed the Fennell Four Phase Model of chronic illness. Fennell says people commonly experience four phases as they learn to incorporate their changed physical abilities or psychological outlook into their personality and lifestyle: Crisis, Stabilization, Integration, and Resolution.

Established by the investment banking firm Wyatt Matas, the term Care Cycle Management is a chronic care business model that integrates interventional disease management with care delivery to manage the care of high-cost patients.

The Flinders Human Behaviour & Health Research Unit (based in Adelaide, South Australia) has developed the Flinders ProgramTM, a generic set of tools and processes that allows for assessment of chronic condition management behaviours, collaborative identification of problems and goal setting leading to the development of individualised care plans with the goal of raising the quality of life for people living with chronic disease. The Flinders ProgramTM has been adapted to specific contexts to meet the needs of Indigenous Australians and veterans'.