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Finding Solutions in the Management of Multiple Chronic Conditions

 From AMN Healthcare NewsBy Jennifer Larson, contributorApril 11, 2013 - Effectively managing one chronic condition is challenging. Double or triple that number, and that’s when chronic disease management really gets complicated--for patients and providers.Unfortunately, the situation is not rare; in fact, one-quarter of the U.S. population is living with multiple chronic conditions, and among the 65 and older population, it is three times that number, or 75 percent. And the numbers are not expected to decline.“If present trends continue, we will see an increase in the number of people with multiple chronic conditions,” said Mary Janevic, MPH, PhD, an assistant research scientist with the Center for Managing Chronic Disease at the University of Michigan.In 2009, the U.S. Department of Health and Human Services (HHS) established an Initiative on Multiple Chronic Conditions that focuses on the challenges posed by the growing trend. Then in 2010, HHS produced a Strategic Framework on Multiple Chronic Conditions that brought together the public and the private sector to collaborate on responses to the challenges. And earlier this year, the Centers for Medicare and Medicaid Services (CMS) announced it was launching a new Medicare Chronic Conditions Dashboard as a tool for professionals to obtain more information on chronic conditions and their costs.Even with these additional resources, the challenges of chronic disease management are likely to persist. And many experts say that it will take some systemic changes to make serious inroads.“Coordinated care is going to become more and more critical, as we have more and more patients with multiple chronic diseases,” said Angela Golden, DNP, FNP-C, president of the board of directors of the American Association of Nurse Practitioners (AANP).A chronic trendSeveral factors are contributing to the growth in multiple chronic conditions, noted Janevic.Notably, the population is aging; the first wave of baby boomers has already become eligible for Medicare. Also, some chronic illnesses such as diabetes are becoming more prevalent. And as people live longer, their chances of living with at least one chronic condition also increase.“It’s absolutely not going to go away,” predicted Candace DeMatteis, policy director for the Partnership to Fight Chronic Disease (PFCD).The growth in multiple chronic conditions will continue to pose challenges to the healthcare system. In 2012, the National Center for Health Statistics reported a rise in the percentage of adults aged 45 to 64 with at least two common chronic conditions, increasing from 16.1 percent to 21 percent over the past decade.This trend is already costly, too. According to HHS, the care of the one-quarter of Americans with multiple chronic conditions accounts for about 66 percent of the country’s total healthcare spending.The necessity for systemic changeThe current system was designed to respond well to a crisis and manage it during the short term, said DeMatteis. “That does not work well at all for chronic disease,” she said. “It needs to be much more preventive in focus.”In fact, a white paper published in October 2012 by the Partnership to Fight Chronic Disease stated, “The health care delivery system also presents challenges to prevention in the disconnect between medical care, public health, and community services; the reactive nature of a system focused on acute needs; and the interplay with socioeconomic issues that are not conducive to adopting healthy behaviors.” It noted that prevention is crucial because several chronic conditions have risk factors in common, like “tobacco use…obesity, alcohol misuse, poor nutrition, and low physical activity.”Prevention and wellness must be placed at the forefront, said Golden, and because the management of multiple conditions can be very complex, a greater emphasis on care coordination is also paramount. Yet, reimbursements are not yet aligned with a model that focuses on ongoing management of multiple chronic diseases--and that can be challenging for healthcare providers.“A lot of what it is that we would like to do for our patients is non-reimbursable,” Golden said. “So it has to be done after hours.”She continued, “When you talk about how to coordinate care, there has to be a way to pay for it.”The Chronic Care Model, developed with funding by the Robert Wood Johnson Foundation (RWJF), cites lack of care coordination as one of the major deficiencies in the way that chronic conditions are currently managed. DeMatteis noted that the Affordable Care Act’s emphasis on team-based care and collaboration among providers could be helpful.Other deficiencies cited by the model include lack of active follow-up to ensure best outcomes, and inadequate training of patients to manage their conditions. The Chronic Care Model is now the core of the RWJF’s national program, Improving Chronic Illness Care.When patients are not adequately trained or educated to manage their chronic conditions, it can become overwhelming. If patients are too daunted to even try to manage their conditions, that’s another indicator for the need of some sort of systemic change.“Particularly for those trying to manage these very complex health regimens, it can be problematic just trying to understand and synthesize information from multiple providers and keep track, and making sense of it,” said Janevic.Adequately managing chronic conditions also assumes that the patients have a reasonable level of health literacy, but that isn’t always the case. Only about 12 percent of the adult population is considered to have a proficient level of health literacy, according to the National Assessment of Adult Literacy. As the National Patient Safety Foundation cautions, limited health literacy is linked with lower treatment compliance and more medication errors.Janevic said, “You might be trying to explain there’s a 3 percent chance of this and a 12 percent chance of that, but for someone who doesn’t have a high health literacy [level], it doesn’t mean much.”Healthcare systems can provide help to those patients through a number of avenues, including classes, education on goal-setting and collaboration with relevant community resources. They can also find ways to provide ongoing support to help patients manage their conditions, even when patients’ circumstances change.“That’s a helpful way of thinking of it: not just as initial education, but as ongoing support the patient needs,” said Janevic.Golden said she is encouraged by the success of programs such as nurse-managed congestive heart failure clinics that work with people to manage their conditions.“I think there are so many innovative models, and I think we’ve got to be watching for those and how they fit into various communities,” she said. “I don’t think there’s a one-size-fits-all. We all need to open our minds to look at new systems and to participate in those when they come in.”