Keywords
Chronic Care Model
Chronic diseases
Governance
Integrated care
Submitted : 2024-04-13
Accepted : 2024-04-28
Published : 2024-05-13
Abstract
In recent years, the incidence rate of chronic diseases has shown a steady increase in every industrialized country. The almost logarithmic trend of the number of people living with chronic diseases is constantly on the rise. Each predictive statistical model indicates a strong impact on national health systems at the level of the organization of care and management costs. It is urgent to systematically introduce an evidence-based care model in chronic care management such as the Chronic Care Model. The Chronic Care Model is the reference model for WHO. The Chronic Care Model allows for personalized, holistic, multi-professional assistance, characterized by a strong humanization of care, preventive interventions, and relationships between healthcare professionals, patients, and caregivers as a system of care and assistance. The fundamental roles are social integration and the improvement of the quality of life of patients. The Chronic Care Model involves the use of a computerized system of information flow and telemedicine and trained healthcare professionals. The Chronic Care Model showed an improvement in the quality of life, a reduction in the number of hospitalizations, better adherence to therapies, and a reduction in costs.
References
Kinsella K, He W, 2009, An Aging World: 2008. US Census Bureau. International Population Reports (P95/09-1). US Gov Printing Office, viewed 5 Feb 2021, https://www.census.gov/content/dam/Census/library/publications/2009/demo/p95-09-1.pdf
World Health Organization (WHO), 2012, World Health Day 2012 – Ageing and Health – Toolkit for Event Organizers. WHO, viewed 5 Feb 2021, https://www.afro.who.int/media-centre/events/world-health-day-2012-ageing-and-health
GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018, Global, Regional, and National Incidence, Prevalence, and Years Lived with Disability for 354 Diseases and Injuries for 195 Countries and Territories, 1990–2017: A Systematic Analysis for the Global Burden of Disease Study 2017. Lancet, 392(10159): 1789–1858. https://doi.org/10.1016/S0140-6736(18)32279-7
Italian Ministry of Health, 2016, Piano Nazionale della Cronicità: Accordo tra lo Stato, le Regioni e le Province Autonome di Trento e di Bolzano del 15 Settembre 2016 [National Chronicity Plan: Agreement between the State, the Regions, and the Autonomous Provinces of Trento and Bolzano of September 15, 2016], viewed 5 Feb 2021, https://www.salute.gov.it/imgs/C_17_pubblicazioni_2584_allegato.pdf
IRCCS – INCRA Ancona per l’Agenzia Nazionale per L’invecchiamento [IRCCS – INCRA Ancona for the National Aging Agency, 2010, 1st Italian Conference on Access to Care in Chronic Diseases, September 21, 2010: L’assistenza Agli Anziani Non Autosufficienti in Italia 4° Rapporto (2012) N.N.A. (Network Non Autosufficienza) [Care for Non-Self-Sufficient Elderly People in Italy 4th Report (2012) N.N.A. (Non-Self-Sufficiency Network)]. Federazione delle Associazioni di Volontariato in Oncologia (FAVO), Rome.
National Observatory on Health in the Italian Regions, 2019, Patologie Croniche in Costante Aumento in Italia con Incremento Della Spesa Sanitaria. La Cronicità non Colpisce Tutti Allo Stesso Modo: Si Confermano le Diseguaglianze di Genere, Territoriali, Culturali e Socio Economiche [Chronic Diseases are Constantly Increasing in Italy, Leading to a Rise in Healthcare Spending. Chronicity Does Not Affect Everyone Equally: Gender, Territorial, Cultural, and Socioeconomic Inequalities Persist], viewed 5 Feb 2021, https://www.osservatoriosullasalute.it/wp-content/uploads/2019/02/Focus-1-Osservasalute-La-cronicità-in-Italia-feb-2019.pdf
Council of the European Union, 2013, Reflection Process: Innovative Approaches for Chronic Diseases in Public Health and Healthcare Systems – Discussion, viewed 5 Feb 2021, https://health.ec.europa.eu/system/files/2016-11/reflection_process_cd_final_report_en_0.pdf
Wagner EH, Austin BT, Von Korff M, 1996, Organizing Care for Patients with Chronic Illness. Milbank Q, 74(4): 511–544.
Wagner EH, 1997, Managed Care and Chronic Illness: Health Services Research Needs. Health Serv Res, 32(5): 702–714.
Wagner EH, 1998, Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Eff Clin Pract, 1(1): 2–4.
Wagner EH, Hayashida CT, 1990, Implementing a Multipurpose Information Management System: Some Lessons and a Model. J Long Term Care Adm, 18(1): 15–20.
Wagner EH, Austin BT, Davis C, et al., 2001, Improving Chronic Illness Care: Translating Evidence into Action. Health Aff (Millwood), 20(6): 64–78. https://doi.org/10.1377/hlthaff.20.6.64
Yeoh EK, Wong MCS, Wong ELY, et al., 2018, Benefits and Limitations of Implementing Chronic Care Model (CCM) in Primary Care Programs: A Systematic Review. Int J Cardiol, 258: 279–288. https://doi.org/10.1016/j.ijcard.2017.11.057
Stellefson M, Dipnarine K, Stopka C, 2013, The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review. Prev Chronic Dis, 10: E26. https://doi.org/10.5888/pcd10.120180
Coleman K, Austin BT, Brach C, et al., 2009, Evidence on the Chronic Care Model in the New Millennium. Health Aff (Millwood), 28(1): 75–85. https://doi.org/10.1377/hlthaff.28.1.75
Bodenheimer T, Wagner EH, Grumbach K, 2002, Improving Primary Care for Patients with Chronic Illness. JAMA, 288(14): 1775–1779. https://doi.org/10.1001/jama.288.14.1775
Malara A, 2016, Il Chronic Care Model Come Esempio di Sanità D’iniziativa [The Chronic Care Model as an Example of Proactive Healthcare], in La Cronicità: Impatto Epidemiologico Nel Terzo Millennio [Chronicity: Epidemiological Impact in the Third Millennium], viewed 5 Feb 2021, http://www.attidellaaccademialancisiana.it/47/19/articolo/Il-Chronic-Care-Model-come-esempio-di-sanita-d-iniziativa
Facchinetti G, D’Angelo D, Piredda M, et al., 2020, Continuity of Care Interventions for Preventing Hospital Readmission of Older People with Chronic Diseases: A Meta-Analysis. Int J Nurs Stud, 101: 103396. https://doi.org/10.1016/j.ijnurstu.2019.103396
Iavarone D, 2016, La Transition of Care, L’infermiere e la Continuità Delle Cure [The Transition of Care, the Nurse, and Continuity of Care]. L’Infermiere, 53(6): e21–e27.
Fortuna RJ, Nagel AK, Rocco TA, et al., 2018, Patient Experience with Care and Its Association with Adherence to Hypertension Medications. Am J Hypertens, 31(3): 340–345. https://doi.org/10.1093/ajh/hpx200
Johansen AS, Vracko P, West R, 2020, The Evolution of Community-Based Primary Health Care, Slovenia. Bull World Health Organ, 98(5): 353–359. https://doi.org/10.2471/BLT.19.239616
Barbato A, Meggiolaro A, Rossi L, et al., 2015, [Tuscan Chronic Care Model: A Preliminary Analysis]. Ig Sanita Pubbl, 71(5): 499–513.
Elissen AMJ, Steuten LMG, Lemmens LC, et al., 2013, Meta-Analysis of the Effectiveness of Chronic Care Management for Diabetes: Investigating Heterogeneity in Outcomes. J Eval Clin Pract, 19(5): 753–762. https://doi.org/10.1111/j.1365-2753.2012.01817.x
Drewes HW, Steuten LM, Lemmens LC, et al., 2012, The Effectiveness of Chronic Care Management for Heart Failure: Meta-Regression Analyses to Explain the Heterogeneity in Outcomes. Health Serv Res, 47(5): 1926–1959. https://doi.org/10.1111/j.1475-6773.2012.01396.x
Nicoll R, Robertson L, Gemmell E, et al., 2018, Models of Care for Chronic Kidney Disease: A Systematic Review. Nephrology (Carlton), 23(5): 389–396. https://doi.org/10.1111/nep.13198
Barr VJ, Robinson S, Marin-Link B, et al., 2003, The Expanded Chronic Care Model: An Integration of Concepts and Strategies from Population Health Promotion and the Chronic Care Model. Hosp Q, 7(1): 73–82. https://doi.org/10.12927/hcq.2003.16763
de Silva D, 2011, Evidence: Helping People Help Themselves. The Health Foundation, viewed 5 Feb 2021, https://www.health.org.uk/publications/evidence-helping-people-help-themselves
Moll SE, Gewurtz RE, Krupa TM, et al., 2015, “Do-Live-Well”: A Canadian Framework for Promoting Occupation, Health, and Well-Being. Can J Occup Ther, 82(1): 9–23. https://doi.org/10.1177/0008417414545981
Lim CY, Berry ABL, Hirsch T, et al., 2017, Understanding What is Most Important to Individuals with Multiple Chronic Conditions: A Qualitative Study of Patients’ Perspectives. J Gen Intern Med, 32(12): 1278–1284. https://doi.org/10.1007/s11606-017-4154-3
Hutchinson SL, Nimrod G, 2012, Leisure as a Resource for Successful Aging by Older Adults with Chronic Health Conditions. Int J Aging Hum Dev, 74(1): 41–65. https://doi.org/10.2190/AG.74.1.c
Janke MC, Jones JJ, Payne LL, et al., 2012, Living with Arthritis: Using Self-Management of Valued Activities to Promote Health. Qual Health Res, 22(3): 360–372. https://doi.org/10.1177/1049732311421179
Smallfield S, Molitor WL, 2018, Occupational Therapy Interventions Supporting Social Participation and Leisure Engagement for Community-Dwelling Older Adults: A Systematic Review. Am J Occup Ther, 72(4): 7204190020p1–7204190020p8. https://doi.org/10.5014/ajot.2018.030627
Hutchinson SL, Fenton L, 2018, Promising Practices for Making Recreation Programming Matter for People who Experience Mental Illness. Community Ment Health J, 54(4): 496–505. https://doi.org/10.1007/s10597-017-0157-0
Hutchinson SL, Lauckner H, 2020, Recreation and Collaboration Within the Expanded Chronic Care Model: Working Towards Social Transformation. Health Promot Int, 35(6): 1531–1542. https://doi.org/10.1093/heapro/daz134
Montague TJ, Gogovor A, Krelenbaum M, 2007, Time for Chronic Disease Care and Management. Can J Cardiol, 23(12): 971–975. https://doi.org/10.1016/s0828-282x(07)70859-0
Nolte E, Knai C, McKee M, 2008, Managing Chronic Conditions: Experience in Eight Countries. European Observatory on Health Systems and Policies, Brussels.
Hofmarcher MM, Oxley H, Rusticelli E, Improved Health System Performance Through Better Care Coordination. OECD Health Working Papers 30, OECD Publishing, Paris. https://doi.org/10.1787/246446201766
The Platforms: Policy, Practice, Research. EuroHealthNet, viewed 28 July 2021, https://eurohealthnet.eu/about-us/policy-practice-and-research-platforms/
Centro Nazionale Malattie Rare (CNMR), Consensus Conference, June 11–13, 2014: “Linee di Indirizzo per L’utilizzo Della Medicina Narrativa in Ambito Clinico-Assistenziale, per le Malattie Rare e Cronico-Degenerative” [“Guidelines for the Use of Narrative Medicine in Clinical-Care Settings, for Rare and Chronic-Degenerative Diseases]. CNMR, Rome.
Italian College of General Practice and Primary Care (SIMG), 2020, Documento di Indirizzo per la Malattia Renale Cronica [Guidance Document for Chronic Kidney Disease], viewed 19 Apr 2021, https://www.simg.it/document-di-indirizzo-per-la-malattia-renale-cronica/
Minutolo R, De Nicola L, Mazzaglia G, et al., 2008, Detection and Awareness of Moderate to Advanced CKD by Primary Care Practitioners: A Cross-Sectional Study from Italy. Am J Kidney Dis, 52(3): 444–453. https://doi.org/10.1053/j.ajkd.2008.03.002
Federation of Associations of Hospital Doctors on Internal Medicine (FADOI), 2012, Linea Guida 23: Identificazione, Prevenzione e Gestione Della Malattia Renale Cronica Nell’adulto [Guideline 23: Identification, Prevention, and Management of Chronic Kidney Disease in Adults], viewed 18 Apr 2021, https://www.fadoi.org/wp-content/uploads/2017/05/linee-guida-Malattia-renale-cronica-adulto.pdf
Montes JMG, Elena MJS, Romera MV, 2020, The Influence of Coping and Personality Styles on Satisfaction with Life in Patients with Chronic Kidney Disease. Psychol Belg, 60(1): 73–85. https://doi.org/10.5334/pb.518
Dinh TTH, Bonner A, Clark R, et al., 2016, The Effectiveness of the Teach-Back Method on Adherence and Self-Management in Health Education for People with Chronic Disease: A Systematic Review. JBI Database System Rev Implement Rep, 14(1): 210–247. https://doi.org/10.11124/jbisrir-2016-2296
Sequist TD, Holliday AM, Orav EJ, et al., 2018, Physician and Patient Tools to Improve Chronic Kidney Disease Care. Am J Manag Care, 24(4): e107–e114.
Agenzia Regionale di Sanità della Toscana (ARS), Che Cos’è la Sanità D’iniziativa [What is Proactive Healthcare], viewed 29 July 2021, https://www.ars.toscana.it/aree-dintervento/problemi-di-salute/malattiecroniche/news/1578-che-cose-la-sanita-diniziativa.html