Comprehensive Care Coordination for Chronically Ill Adults

Cheryl Schraeder, Paul S. Shelton

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9780470960875
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Breakthroughs in medical science and technology, combined with shifts in lifestyle and demographics, have resulted in a rapid rise in the number of individuals living with one or more chronic illnesses. Comprehensive Care Coordination for Chronically Ill Adults presents thorough demographics on this growing sector, describes models for change, reviews current literature and examines various outcomes.

Comprehensive Care Coordination for Chronically Ill Adults is divided into two parts. The first provides thorough discussion and background on theoretical concepts of care, including a complete profile of current demographics and chapters on current models of care, intervention components, evaluation methods, health information technology, financing, and educating an interdisciplinary team. The second part of the book uses multiple case studies from various settings to illustrate successful comprehensive care coordination in practice. Nurse, physician and social work leaders in community health, primary care, education and research, and health policy makers will find this book essential among resources to improve care for the chronically ill.

Part 1

Theoretical concepts

1. Chronic illness
Paul Shelton, EdD, Cheryl Schraeder, RN, PhD, FAAN, Michael K. Berkes, BS, MSW Candidate, and Benjamin Ronk, BA

2. Overview
Cheryl Schraeder, RN, PhD, FAAN, Paul Shelton, EdD, Linda Fahey, RN, MSN, Krista L. Jones, DNP, MSN, ACHN, RN, and Carrie Berger, BA, MSW Candidate

3. Promising practices in acute/primary care
Randall S. Brown, PhD, Arkadipta Ghosh, PhD, Cheryl Schraeder, RN, PhD, FAAN, and Paul Shelton, EdD

4. Promising practices in integrated care
Patricia J. Volland, MSW, MBA, and Mary E. Wright

5. Intervention components
Cheryl Schraeder, RN, PhD, FAAN, Cherie P. Brunker, MD, Ida Hess, MSN, FNP-BC, Beth A. Hale, PhD, RN, Carrie Berger, BA, MSW Candidate, and Valerie Waldschmidt, BSE

6. Evaluation methods
Robert Newcomer, PhD, and L. Gail Dobell, PhD

7. Health information technology
David A. Dorr, MD, MS, and Molly M. King, BA

8. Financing and payment
Julianne R. Howell, PhD, Robert Berenson, MD, and Patricia J. Volland, MSW, MBA

9. Education of the interdisciplinary team
Emma Barker, MSW, Patricia J. Volland, MSW, MBA, and Mary E. Wright

Chapter 1

Chronic illness

Paul Shelton, Cheryl Schraeder, Michael Berkes, and Benjamin Ronk

Introduction

The demographic landscape of the United States has changed significantly. Americans are living longer than ever before. The average life span has increased from 47 years for individuals born in 1900 to 78 years for those born in 2006 (National Center for Health Statistics [NCHS] 2010). The result has been an exponential growth in the number and percentage of older Americans, which is unique to our nation's history. This longevity is primarily due to advances in modern medical science that have produced new screening and diagnostic technologies, pharmaceuticals, and medical procedures, as well as comprehensive initiatives that have greatly diminished or eliminated infectious diseases and improved public health problems. Americans living in the twenty-first century can expect to live longer than any previous generation. Longer life expectancy combined with the baby-boom generation, individuals born after World War II from 1946 through 1964, will double the number of individuals who are 65 years and older during the next 25 years.

This aging of America has created problems and challenges for our health care system. As longevity has increased so have the numbers of Americans living with chronic illnesses. Chronic illnesses afflict people of all ages, and although a majority of individuals living with chronic illnesses are not elderly, the likelihood of having a chronic illness increases dramatically with advancing age. Current projections estimate that approximately 66% of Americans 18 years of age and older suffer from at least one chronic illness, and as much as 80% of individuals 50 years of age and older suffer from at least one chronic illness (Machlin et al. 2008). These individuals seek and receive health care in a system that is designed, structured, and financed for treating acute episodes of care. The current system has been extensively criticized for being overly deficient in providing coordinated care for individuals with chronic illnesses who are primarily insured through Medicare and Medicaid (Institute of Medicine [IOM] 2001), and who are not receiving optimum chronic illness care (McGlynn et al. 2003).

The new generation of older Americans, the baby boomers, will be distinctly different from previous generations. They will be more educated, have more discretionary income, be more racially diverse, have fewer children, and have less disability compared to their parent's generation (Federal Interagency Forum on Aging-Related Statistics 2008; IOM 2008). Their sheer numbers alone will dramatically affect the future of our health care system. During the next two decades the number of older adults will double, from approximately 37 million to over 70 million, accounting for an 8% overall increase within the total population, currently from 12% to 20% (IOM 2008). While this approaching demographic shift has been anticipated for over 50 years, our health care system is not prepared for its arrival. More providers with specialized training and resources, and new approaches to delivering chronic care are needed to meet the aging population's health care needs (Bodenheimer et al. 2009; IOM 2008). Presenting a stark reality, the IOM (2008) asserted that providers are inadequately prepared in general knowledge of geriatrics, the health care workforce is not large enough to meet older patients’ needs, and the scarcity of workers currently specializing in geriatrics is even more pronounced. These shortages will become more pronounced in the future.

According to the IOM (2001), improving care for the chronically ill is one of the most important health care challenges facing our nation today. The IOM report makes clear that there are no easy means or readily available answers to improving this care. Despite some consensus regarding what optimum chronic care should resemble, its delivery remains elusive (Wolff & Boult 2005). Research has demonstrated that achieving and sustaining improvements in the care coordination and medical management of these chronically ill adults is extremely difficult and is hindered by a general lack of knowledge, experience, and financial mechanisms necessary for the optimal care for this large and ever expanding segment of the population (Norris et al. 2008; Wallace 2005). Dysfunctional incentives have created fragmentation within our current system which fails to address the underlying causes of disease, and far too many care decisions are not under the control of clinicians and patients.

In this chapter we (1) define chronic illness, its general prevalence, and the main causes for its dramatic increase; (2) present a demographic profile of the adult population 55 years of age and older, (3) present a demographic profile for adults 65 years of age or older, with additional characteristics related to Medicare beneficiaries; and (4) present specific characteristics of chronically ill adults. A basic understanding of the scope and magnitude of chronic illness is necessary in order to begin to design, implement, and evaluate effective comprehensive care coordination programs for the tidal wave of chronically ill adults who will hit the health care system, especially Medicare, with brute force in the very near future.

What is a chronic illness?

Chronic illness is a general term that refers to a diagnosed illness, functional limitation, or cognitive impairment that lasts at least a year, places limits on a person's daily activities, and often requires regular attention and medical care (Hwang et al. 2001; Anderson 2010). Chronic illnesses are often preventable, usually develop in later adulthood, and last for years. They are typically managed with proper care from clinicians, self-care activities, and often with help from family members acting as informal caregivers. Some of the most prevalent chronic illnesses include arthritis, asthma/bronchitis, cancer, cardiovascular disease, depression, and diabetes (American Association of Retired Persons [AARP] 2009a; Center for Disease Control and Prevention [CDCP] 2009).

Having a chronic illness affects people in multiple ways. Many chronic illnesses reduce a person's quality of life and/or limits their performance of normal activities without some form of assistance. Approximately 20% of people who have a chronic illness also have one or more limitations in activities of daily living (ADLs) or instrumental activities of daily living (IADLs; Agency for Healthcare Research and Quality [AHRQ] 2006). Typically, people with multiple chronic illnesses have significantly higher rates of hospital admissions and emergency room (ER) visits, and experience higher medical expenses compared to people without a chronic illness. Chronic illnesses account for 70% of annual mortality rates; heart disease, cancer, and stroke are the causes of 50% of all deaths each year (CDCP 2009).

The prevalence of chronic illness is steadily on the rise, and will increase exponentially in the future. In 1995 there were approximately 118 million individuals living with a chronic illness. This number is projected to increase 45% by 2030 to 171 million (NCHS 2010). In 2006, over 20% of all individuals had at least one chronic illness, and 28% had two or more (Anderson 2010). Hypertension was the most common chronic illness (33%), followed by lipid disorders (22%), upper respiratory diseases (19%), non-traumatic joint disorders (17%), heart disease (14%), diabetes mellitus (13%), eye disorders (11%), asthma (10%), and chronic respiratory infections (10%; Anderson 2010).

There are several factors that contribute to the increase of these illnesses. An aging population is a prominent factor, as the proportion of individuals with chronic illnesses increases dramatically with age. For example, one in fifteen children has multiple chronic illnesses (7%) compared to three out of four elderly individuals (75%). National statistics highlight these differences for distinct age groups (AHRQ 2006): 27% of children from birth to age 19 have one chronic illness, 7% have two or more; 40% of adults aged 20 to 44 have one chronic illness, 17% have two or more; 68% of adults aged 45 to 64 have one chronic illness, 43% have two or more; and 91% of the elderly have one chronic illness while 73% have two or more. In comparison, respiratory disease (36%) and asthma (30%) are the most prominent pediatric chronic illnesses, while hypertension (60%), cholesterol disorders (41%), arthritis (28%), heart disease (25%), and eye disorders (23%) are the most common in adulthood (Anderson 2010).

The increased use of evidence-based clinical guidelines have broadened the definitions of disease, and advances in treatment modalities have led to more people being screened and subsequently diagnosed with chronic illnesses. Treatment advances have allowed providers to diagnose chronic illnesses and identify people who might benefit from medications or therapies at an earlier age, while public awareness of certain chronic illnesses has led to more people requesting testing and treatment (AARP 2009a). Two examples that highlight these advances are the increased percentage of adults that are either under surveillance or are being actively treated for hypertension (Ostchega et al. 2007) and/or high cholesterol (Hyre et al. 2007), with the intent of preventing or delaying the onset of heart disease or stroke. As a result, the most prominent form of chronic illness treatment with adults is hypertension and elevated cholesterol.

Several behaviors identified with the American lifestyle are also responsible for the increase in chronic illnesses. Three modifiable health risk behaviors, lack of physical activity, tobacco use, and poor nutrition (CDCP 2009), are linked to several chronic illnesses, including chronic obstructive pulmonary disease (COPD), diabetes, and cancer (AARP 2009a). Less than half of all adults (48.8%) meet Healthy People 2010 minimum recommendations for physical activity, and 23% report no leisure-time physical activity at all during the month (Carlson et al. 2008). Approximately 20% of adults (NCHS 2010) and 23% of high school students are cigarette smokers (CDCP 2008).

Obesity has reached epidemic proportions in America and is one of the biggest public health challenges the country has ever faced (U.S. Department of Health and Human Services 2001). An estimated 34% of adults aged 20 years and over are overweight, 34% are obese, and 6% are extremely obese (Flegal et al. 2010), while over 20% of children and teens between the ages of 6 and 19 are obese (Ogden et al. 2008). Body Mass Index (BMI), calculated as weight in kilograms divided by height in meters squared (kg/m2), is commonly used to classify people as overweight (BMI 25.0-29.9), obese (BMI equal to or greater than 30.0), and extremely obese (BMI equal to or greater than 40.0). Researchers at RAND Health (2002) estimated that obese individuals have 67% more chronic illnesses than normal-weight individuals, and long-term smokers have 25% mo...

Table of contents

• Cover
• Title Page
• Copyright
• Editors and Contributors
• Acknowledgments
• Introduction
• Part 1: Theoretical concepts
• Part 2: Promising practices
• Index
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