Definition

Chronic illnesses are conditions that require ongoing healthcare management and support over a long period of time. While oftentimes preventable, these conditions may take years to become fully established and can impact the social, mental and economic aspects of a person’s life. Chronic illnesses may require complex disease management, care coordination, and long term and systematic approaches to treatment. Common acute chronic illness/conditions may include diabetes, heart disease, asthma, lung cancer, chronic obstructive pulmonary disease, and some cancers. In addition, health care experts have expanded the definition to HIV/AIDS, depressionand certain other mental health conditions, and long-term care physical disabilities.

Relevance

Preventing chronic conditions is a key issue for industrialized countries because of the growth and health complexity of the aging population, the high cost of treating and maintaining the quality of life for those with chronic conditions, and the challenges of treating chronic conditions in health care systems focused on acute care. Approximately 45% of chronic disease deaths occur in people under 70 years of age. A study in the United States in 2008 indicated that the percentage of adults with chronic conditions has grown from 28 percent in 1997 to 31 percent in 2006.

Health care systems have not historically been designed to treat complex, costly chronic conditions. Populations are now living longer with multiple chronic conditions, so that the complexity and cost of chronic disease management is straining the health care systems in many counties.

A number of prominent chronic diseases are linked by common and preventable biological risk factors, notably high blood pressure, high blood cholesterol and overweight, and by related major behavioral risk factors: unhealthy diet, physical inactivity and tobacco use. Action to prevent these major chronic diseases globally should focus on controlling these and other key risk factors.

Context

Each country’s traditions, culture, and political economy can impact when and how they can implement strategies to address chronic conditions.

Certain countries may need to address structural issues not directly related to health care before they can fundamentally reform their health care system. For example, poor diet and exercise are two of the main risk factors for four major chronic conditions. A country will have a minimal impact in addressing these risk factors if communities do not have sufficient places to exercise (such as public parks), have a safe environment to exercise (limiting crime in an area), and if their agricultural policy or food industry continues to produce and to promote unhealthy food options.

Additionally, success depends on re-engineering many aspects of healthcare delivery and finance, improved patient education and provider training and re-training, creating new team-based models of care, development of social marketing, and effective use of health care technologies and self- and home-care regimens. Some countries place more emphasis than others on prevention, health promotion, and healthy lifestyles while others lay a focus on better care coordination among providers and disease management programs.

Each country reviewed below takes a different approach. Most are experimenting with a variety of strategies with varied success. Different variables may impact how well poised a country is to execute chronic illness health care reform. Variables include the perceived “urgency” of the problem, the health information technology capacity, and how clients are identified for treatment or chronic disease interventions. The system by which each country finances health care can also impact how a country manages chronic conditions and dictate where opportunities for reform exist.

Innovative Options to Addressing Chronic Conditions
Country Examples

Finland

Finland reduced the incidence of heart disease by creating a large-scale community intervention involving consumers, schools, and social and public health agencies. The specific interventions that addressed heart disease included legislation banning tobacco advertising, the introduction of low-fat dairy and vegetable oil products, changes in farmers’ payment schemes (linking payment for milk to protein rather than fat content), and incentives for communities achieving the greatest cholesterol reduction.

United States

A number of communities in the United States, such as Providence St. Peter Family Clinic in Olympia, Washington, Universa Health Care (Health Maintenance Organization in New York State), Vanderbilt Medical Center, and the American Medical Association in their medical home model, have implemented the chronic care model (CCM), a comprehensive concept of care for the chronically ill. The CCM model has been successfully implemented in many settings including community health systems, multispecialty clinics, solo practitioners, health plans, integrated health systems, community-based organizations, and academic health centers. The CCM includes key elements to ensure high quality chronic disease care and is constantly reviewing additional improvements in CCM strategies. CCM elements include community participation, health system interaction, self-management support, delivery system re-design, decision supports, and use of clinical information systems. The CCM has recently been discussed as a model to address health disparities as well.

This evidence-based model results in “productive interactions” between informed, activated patients who take part in their care and a prepared, proactive team of care providers with adequate resources and expertise to care for these individuals.

The CCM is being successfully adapted in some European countries (Denmark, Spain, UK, Germany) and in Israel.

New Zealand

Through its Care Plus program, New Zealand provides additional funding for primary health organizations to give better care to people who use high levels of sevices or have special needs. The overall approach to care has changed from disease and treatment-specific services towards health and prevention activities.

High-risk patients with chronic conditions receive expanded, better coordinated, lower cost services from a range of health care professionals. In particular, they receive low or reduced cost access to nurses and/or physicians with appropriate expertise, continuity of care that includes a care plan jointly developed with the patient, and ongoing support through pre-planned regular reviews, as well as advice on improving health outcomes through better self management (with support to identify and meet realistic health care goals).

Germany

Germany incentivizes providers, patients with chronic conditions, and payers alike in its disease management programs. While since 2004 statutory health insurers have to offer disease management programs and are compensated for taking on higher risk patients, enrollment of physicians and of patients is voluntary. Millions of patients chose to enroll, with half of them participating in Diabetes 2 disease management programs (DMPs) – one of the world’s largest DMP experiences. Acceptance is growing as care (process quality) and patient satisfaction improve. Health status and quality of life has shown to be significantly higher for enrollees than for control groups of patients with identical conditions but not enrolled. Germany has also set up an attractive contractual incentive scheme for integrated care networks to provide better coordinated population-oriented care. The new contracts enable cooperation between health insurers, healthcare providers, non-medical healthcare professionals such as speech therapists and occupational therapists, and others, all of whom had been previously working in isolation or single-handed practice.

Spain

Catalonia, Spain implemented a pioneering integrated health care pilot that transformed who the government paid for health care services for the chronically ill. The Catalan Health Institute (single purchaser) substituted individual health provider contracts for capitation-based contracts with integrated care coordination.

Australia

Australia is considering establishing general practitioner (GP) super clinics that shift from primary care to more comprehensive care, especially for chronic conditions. A component of this initiative is to provide capital funding to build facilities that encourage multidisciplinary and integrated primary and chronic care.