Chronic illnesses such as diabetes, heart disease, asthma, depression and others account for three quarters of the nation's health care costs. Writing in the December 15 issue of Annals of Internal Medicine, the health researchers point out that "experimental studies have shown a gap between the health care services intended to improve outcomes in chronic illness and the care that patients usually receive.
"This disparity calls for reassessment of the current organization of health care so that chronically ill patients are more likely to receive services that help them live as well as they can for as long as they can."
Michael Von Korff, ScD, and colleagues at the Center for Health Studies, Group Health Cooperative of Puget Sound, and Jessie C. Gruman, PhD, executive director of the Center for the Advancement of Health, write that such care breaks from the traditional doctor-patient relationship by ensuring that patients and physicians work as a team.
"Self-care and medical care are sometimes viewed as competing rather than complementary strategies," they write. "Medical care for chronic illness is rarely effective in the absence of adequate self-care. Self-care and medical care are both enhanced by effective collaboration among...patients and their families and health care providers."
The authors note that earlier research demonstrates that characteristics of quality care apply across multiple chronic illnesses and that illness management "does not need to be reinvented for each chronic disease." They identify four "essential elements" of such care:
- Collaborative definition of problems to "harmonize" both physicians' and patients' perspectives. "Providers usually define problems in terms of diagnosis, poor compliance with treatment, or continuing unhealthy behaviors," they write, while "patients are more likely to define problems in terms of pain, symptoms, interference with functioning, emotional distress, difficulty carrying out treatments or lifestyle changes, or fears about unpredictable health consequences."
- Targeting, goal-setting and developing an action plan. "Patients and providers often initiate many changes at once, which can lead to poor adherence and discouragement.... (Instead) targeting should be done on the basis of both the importance of the problem and patient motivation and readiness for self-care."
- A continuum of self-management training and support. Health plans, they write, can teach patients the skills they need to carry out their regimens, guide behavior changes and provide emotional support. Such services, they say, need to be personalized to each patient's motivation and readiness and aligned with priorities set by the patient and doctor.
- Active, sustained follow-up. By contacting patients at specified intervals, the researchers write, care providers can help patients identify potential complications early, review progress, make changes as needed and reinforce patient efforts.
"As yet, no grand strategy exists for reorganizing health care systems to improve collaborative management of chronic illness," the authors write. "The growth of managed care increases possibilities for collaboration among patients and their families, primary care providers, and specialists, but this potential for improved collaboration has yet to be realized in routine patient care."
The work was supported by a 1996 conference grant from the Robert Wood Johnson Foundation. Annals of Internal Medicine is the official scientific journal of the American College of Physicians.
MEDIA NOTE: For the physicians' perspective on the above article, contact author Edward H. Wagner, MD, MPH, at 206-287-2704, wagnere@mpe.ghc.org . For the patients' perspective, contact author Judith Schaefer, MPH, at 206-287-2077, schajk1@mpe.ghc.org
Posted by the Center for the Advancement of Health (link: www.cfah.org).
Contact: Richard Hebert: rhebert@cfah.org
Journal
Annals of Internal Medicine