Chronic Disease Management

Diabetes, hypertension, congestive heart failure and asthma are some of chronic diseases that are familiar to us. Nowadays the number of people who suffer from these diseases increased. Imbalanced diet, less physical activity and other bad habits such as smoking are major contributors to such diseases.

A guideline for chronic disease management therefore is essential.



Based on British Columbia's Expanded Chronic Care Model, there are several important aspects to manage chronic diseases.

• Community System
  

Its goal is to build healthy public policy, strengthen community action and create supportive environment.

• The Health System

In health system there are international CDM conference, CDM program information days, national chronic care network and CDM quality improvement. All of these programs work to create a culture, organization and mechanisms that promote safe, high quality care as well as to promote collaboration.

• Self-management Support

Each patient need to prepare themselves, set their minds

• Delivery System Design

Delivery System Design includes; living well with a chronic condition, chronic disease management for diverse population, nurse care management, complex chronic patients, targeted interventions (aboriginal populations, homeless populations and hutterites), health/illness and spirituality.The goal is to assure the delivery of effective, efficient clinical care and self-management support that suits with patient's cultural background.

• Decision Support

The aim of decision support is to promote clinical care that is consistent with scientific evidence and patient preferences. The academic detailing, physician education and disease management accreditation influence the decision making.

• Information System

This element focus on multiple sources in delivery of effective and efficient clinical care.

The main points of CDM are :

1. Comprehensive care : Multiprofessional, multidisciplinary, acute care, prevention and promotion
   
2. Integrated care, care continuum, and coordination of different components
3. Population orientation (defined by a specific condition)
   
4. Active client-patient management tools (health education, empowerment, self-care)
   
5. Evidence-based guidelines, protocols and care pathway
6. Information technology and system solutions
7. Continuous quality improvement

However, it is not that easy to implement the chronic care program. Many problems arise, complicate the success of the program. First and foremost, of course regarding the financial flow and incentives. Lack of incentives demotivate health professionals to get involved with CDM program. Research suggests that one of the central obstacles to improved care for patients with chronic disease is the lack of coordination in health care provision. Poor coordination will affect the continuity of care. Another problem is due to lack of efficient use of information and communication technology (ICT), maybe due to high costs and budget-overruns. Not every country can afford ICT iniatives to be put in all of the health care system. A proper evaluation is noteworthy to evaluate effectiveness and cost-effectiveness of various preventive and treatment interventions. If the evaluation is not well established, the policy makers thus are not optimally equipped to make informed decisions to form the future of CDM.


Read more :
1. Chronic disease management and remote patient monitoring - Eurohealth Vol. 15 No. 1, 2009

2. Are disease management programs (DMP) effective in improving quality of care for people with chronic condition? [August 2003]

3. The expanded chronic care model : An integration of concepts and strategies from population health promotion and the chronic care model