Chronic Disease Management, An Issue of Primary Care Clinics in Office Practice Book

Foreword: Teaching Strategies Behind the Principles Joel J. Heidelbaugh xiii

Preface: Chronic Disease Management: The Changing Landscape of Primary Care Brooke Salzman Lauren Collins Emily R. Hajjar xv

Value-Based Reengineering: Twenty-first Century Chronic Care Models Thomas R. Graf Frederick J. Bloom Jr Janet Tomcavage Duane E. Davis 221

The need for improved models of chronic care is great and will become critical over the next years as the Medicare-aged population doubles. Many promising models have been developed by outstanding groups across the country. This article reviews key strategies used by successful models in chronic disease management and discusses in detail how Geisinger has evolved and organized its cohesive delivery model.

The Changes Involved in Patient-Centered Medical Home Transformation Edward H. Wagner Katie Coleman Robert J. Reid Kathryn Phillips Melinda K. Abrams Jonathan R. Sugarman 241

In 2007, the major primary care professional societies collaboratively introduced a new model of primary care: the patient-centered medical home (PCMH). The published document outlines the basic attributes and expectations of a PCMH but not with the specificity needed to help interested clinicians and administrators make the necessary changes to their practice. To identify the specific changes required to become a medical home, the authors reviewed literature and sought the opinions of two multi-stakeholder groups. This article describes the eight consensus change concepts and 32 key changes that emerged from this process, and the evidence supporting their inclusion.

A How To Guide to Creating a Patient-Centered Medical Home George Valko Richard C. Wender Michele Q. Zawora 261

The concept of the patient-centered medical home (PCMH) has been widely embraced as a foundation' for the transformation of health care delivery. Recent evaluations of PCMH pilots validate the initial hypothesis that care provided in the PCMH has the potential to result in better health outcomes at lower cost. However, earning recognition or certification as a PCMH can be a daunting task. This article discusses the process of developing the potential to function as a PCMH, earning formal recognition, and implementing a system of continuous quality improvement to enable the establishment of a mature, sustainable PCMH.

Effective Strategies for Behavior Change Mary Thoesen Coleman Ryan H. Pasternak 281

Strategies that are most effective in both prevention and management of chronic disease consider factors such as age, ethnicity, community, and technology. Most behavioral change strategies derive their components from application of the health belief model, the theory of reasoned action/theory of planned behavior, transtheoretical model, and social cognitive theory. Many tools such as the readiness ruler and personalized action plan form are available to assist health care teams to facilitate healthy behavior change. Primary care providers can support behavior changes by providing venues for peer interventions and family meetings and by making new partnerships with community organizations.

Self-Management Education and Support in Chronic Disease Management Patrick T. McGowan 307

With the changing health care environment, prevalence of chronic health conditions, and burgeoning challenges of health literacy, obesity, and homelessness, self-management support provides an opportunity for clinicians to enhance effectiveness and, at the same time, to engage patients to participate in managing their own personal care. This article reviews the differences between patient education and self-management and describes easy-to-use strategies that foster patient self-management and can be used by health care providers in the medical setting. It also highlights the importance of linking patients to nonmedical programs and services in the community.

Health Information Technology: Transforming Chronic Disease Management and Care Transitions Shaline Rao Craig Brammer Aaron McKethan Melinda B. Buntin 327

Adoption of health information technology (HIT) is a key effort In improving care delivery, reducing costs of health care, and improving the quality of health care. Evidence from electronic health record (EHR) use suggests that HIT will play a significant role in transforming primary care practices and chronic disease management. This article shows that EHRs and HIT can be used effectively to manage chronic diseases, that HIT can facilitate communication and reduce efforts related to transitions in care, and that HIT can improve patient safety by increasing the information available to providers and patients, improving disease management and safety.

Pharmacologic Issues in Management of Chronic Disease Gina DeSevo Jacqueline Klootwyk 345

A significant portion of the adult population uses one or more medications on a regular basis to manage chronic conditions. As the number of medications that patients are prescribed increases, an increase in pharmacoiogic-related issues and complications may occur, such as polypharmacy, inappropriate prescribing, medication nonadherence and nonpersistence, and adverse drug reactions and events. Risk factors and consequences of these issues have been identified and are discussed in this article. In addition, a review is presented of the numerous methods that have been evaluated to help prevent and minimize these pharmacologic issues in the management of chronic disease.

Effective Strategies to Improve the Management of Diabetes: Case Illustration from the Diabetes Health and Wellness Institute Donna Rice Tyson M. Bain Ashley Collinsworth Karen Boyer Neil S. Fleming Esteria Miller 363

Many patients with diabetes do not have access to clinical care or medications, resulting in cases of undiagnosed diabetes or uncontrolled diabetes, especially in patients of low socioeconomic status. Given these considerations, new strategies are needed to control the rampant growth of diabetes and prevent new cases. This article discusses effective strategies for improving the management of diabetes in underserved populations, with special reference to the Juanita J. Craft Diabetes Health and Wellness Institute, a unique partnership between a large, urban integrated health care system, the City of Dallas, and a South Dallas community.

Childhood Asthma: Considerations for Primary Care Practice and Chronic Disease Management in the Village of Care Michael P. Rosenthal 381

Childhood asthma is at historically high levels, with significant morbidity and mortality. Despite more than two decades of improved understanding of childhood asthma care and the evolution of beneficial medications, widespread control remains poor, leading to suboptimal patient outcomes and quality of life. This lack of control results in excessive emergency department use, hospitalizations, and inappropriate and/or unnecessary costs to the health care system. Advanced practice models that incorporate community-based approaches and services for childhood asthma are needed. Innovative, community-included methods of care to address the burden of childhood asthma may provide examples for care of other chronic diseases.

Effective Strategies to Improve the Management of Heart Failure Geoffrey D. Mills Christopher V. Chambers 393

The purpose of this article is to provide resources for primary care physicians to manage heart failure as a chronic disease. We review evidence-based interventions that can be adopted in primary care practices to improve adherence to available guidelines for medication use, promotion of self-care behaviors, transitions of care in acute decompensated heart failure, and end of life care. This information will be valuable to primary care providers who care for patients with heart failure in all care settings but is focused on the management of heart failure in the outpatient setting.

Strategies to Improve the Management of Depression in Primary Care Jürgen Unützer Mijung Park 415

Effective management of depression in the primary care setting requires a systematic, population-based approach, which entails systematic case finding and diagnosis, patient engagement and education, use of evidence-based treatments, including medications and/or psychotherapy, close follow-up to ensure patients are improving, and a commitment to adjust treatments or consult with mental health specialists until depression is significantly improved. Programs in which primary care providers and mental health specialists collaborate effectively using principles of measurement-based stepped care and treatment to target can substantially improve patients' health and functioning while reducing overall health care costs.

Community-Based Partnerships for Improving Chronic Disease Management James Plumb Lara Carson Weinstein Rickie Brawer Kevin Scott 433

With the growing burden of chronic disease, the medical and public health communities are re-examining their roles and opportunities for more effective prevention and clinical interventions. The potential to significantly improve chronic disease prevention and have an impact on morbidity and mortality from chronic conditions is enhanced by adopting strategies that incorporate a social ecology perspective, realigning the patient-physician relationship, integrating population health perspectives into the Chronic Care Model, and effectively engaging communities using established principles of community engagement.

Index 449