The Chronic Care Model, Coursework Example

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is a challenging chronic disease that requires significant attention and ongoing care and treatment in order to improve quality of life for patients on a consistent basis. The Chronic Disease Model represents an alternative means of addressing chronic disease in patients through a comprehensive approach to address outcomes and to be proactive in meeting the needs of the patient population in an effective manner. It is necessary to consider the specific role of this model in treating and managing the symptoms of COPD for patients who suffer from the disease. This group of patients requires a specialized plan of care and treatment that will enable them to address issues regarding quality of life and other matters that have an impact on their health and wellbeing. The treatment of this patient population must also examine the impact of a chronic disease model in the rate and frequency of hospital readmissions for this patient population, particularly as they face common symptom flare ups and other complications throughout the treatment phase. The following discussion will address the role of the Chronic Care Model in greater detail and will consider the impact of this model on the rate of hospital readmissions for patients who suffer from COPD. The primary research question to be considered is as follows: Is it possible for the Chronic Disease Model to be effective in the prevention of frequent hospital readmissions for patients with COPD?

Analysis

The management of chronic disease requires a continuous evaluation of specific resources and opportunities to encourage patients to be proactive in their efforts to manage COPD as best as possible. However, this requires a detailed evaluation and analysis in order to accomplish the intended objectives and to better understand how to address COPD-related symptoms so that the number of hospitalizations required by patients are reduced with the implementation of a chronic disease model. It is necessary to evaluate prior studies in consideration of the Chronic Disease Model in order to determine its potential efficacy in treating patients with COPD so that the likelihood of their hospital readmission rates is decreased as best as possible. A study by Cramm & Nieboer (2012) considers this model with respect to patient responses to treatment and related symptoms of COPD in The Netherlands. Disease Management Programs (DMPs) have become increasingly common in this nation as a means of addressing the complexities of chronic disease that may influence patients’ quality of life through chronic care delivery at the highest possible level. The “Patient Assessment of Chronic Illness Care” has been identified as potential means of understanding the role of “behaviour of professionals and practice teams from the patient’s perspective,” including five scales: 1) patient activation; 2) decision support; 3) tailoring; 4) problem solving; and 5) follow up (Cramm & Nieboer, 2012, p. 2). These criteria were examined in the context of a 20-item questionnaire in order to identify specific measures related to chronic care that impact patients with COPD (Cramm & Nieboer, 2012). In this context, the study included 2,487 patients using a cross-sectional format with either COPD or CVD, and it was determined through the questionnaire responses that age and symptoms of depression play an important role in PACIC scores, thereby demonstrating that these scores were higher when patients experienced limited symptoms related to depression (Cramm & Nieboer, 2012). In a prior study, it was determined that “COPD patients who received interventions with two or more CCM components had lower rates of hospitalisations and emergency/ unscheduled visits, and shorter hospital stays compared with control groups” (Cramm & Nieboer, 2012, p. 4). This is an important reminder of the value of using a chronic care model in order to minimize symptoms, reduce hospitalizations, and improve general quality of life for patients with COPD, particularly when they experience flare ups of the condition that require further treatment (Cramm & Nieboear, 2012). This study provides a positive basis for examining the potential impact of the Chronic Care Model for patients with COPD, particularly as they may struggle with a variety of symptoms that may impact their overall health and wellbeing in many areas, given the effectiveness of this model in treating patients in other areas. The study provides further evidence that this model should be explored in greater detail for patients with COPD and related symptoms.

A study by Cramm, Rutten-Van Molken, & Nieboer (2012) examines the frequency and impact of hospitalizations related to COPD events and how acute care models have been largely utilized for patients with COPD, rather than investing in a comprehensive model that supports the treatment of the condition beyond its acute symptoms. It is believed that “Integrated care models, such as disease-management programmes (DMPs), capture the complexity of coordinated healthcare provision for chronic conditions. DMPs aim to improve the effectiveness and economic efficiency of chronic-care delivery by combining patient-related, professional, and organisational interventions” (Cramm et.al, 2012, p. 2). In this context, it is likely that organizations will benefit from protocols that aim to have a lasting impact on patient care quality of life that go beyond the typical acute symptoms of the disease, thereby creating an environment in which patients might be able to recover more fully and to experience improvements in their daily lives that are essential to their overall wellbeing (Cramm et.al, 2012). This study evaluates the conditions under which the PACIC is influential in the use of the Chronic Care Model and in which there are opportunities to address the integration of a comprehensive model to improve outcomes for COPD patients (Cramm et.al, 2012). A cross-sectional study examined these issues and demonstrated the importance of DMPs in The Netherlands in order to establish a pattern of higher PACIC scores for patients who receive care under these programs versus those who do not (Cramm et.al, 2012). It was believed that the patients who scored higher received improved quality of care over those who did not score at a higher level, and this hypothesis was proven true with the study results, given that patients who received structured care that was collaborative in nature were more likely to score higher on the PACIC, thereby demonstrating that there is significant value to a chronic care model in treating patients with COPD and in demonstrating their ability to respond to treatment in an effective manner (Cramm et.al, 2012). This study reflects the importance of developing new strategies for improvement that will have a lasting impact on patient care quality of life for patients with COPD and in determining how to best move forward in addressing an integrated care environment at the highest possible level (Cramm et.al, 2012). This study also demonstrates the value of a comprehensive approach to COPD that also includes a holistic strategy that includes smoking cessation, exercise therapy, and pharmacotherapy in a combined manner in order to achieve the intended results (Cramm et.al, 2012). This study further supports the belief that a chronic care model is a critical factor in supporting and advancing objectives for patients that will have a lasting impact on their health and wellbeing, particularly when a comprehensive approach is in place that will impact their health at the highest possible level (Cramm et.al, 2012).

A study by Fromer (2011) evaluates the role of chronic care and treatment for patients with COPD, using an approach that goes well beyond the common method to address acute exacerbations of the disease without a long-term strategy in place. It is believed that “The chronic care model and patient-centered medical home combine delivery system redesign, clinical information systems, decision support, and self-management support within a practice, linked with health care organization and community resources beyond the practice. COPD care programs implementing two or more chronic care model components effectively reduce emergency room and inpatient utilization” (Fromer et.al, 2011, p. 605). Under these conditions, it is important to identify the resources that are required to treat patients effectively and to consider the value of developing new ideas to facilitate effective patient outcomes for this population group (Fromer et.al, 2011). Most importantly, it is necessary to identify the specific areas whereby patients will benefit from these practices, using a strategy that supports disease maintenance rather than simply a rescue-based approach (Fromer et.al, 2011). It is of critical importance to address the value of maintenance therapies as part of a larger framework for managing the disease, but to also consider the value of understanding situations in which patients will receive greater quality of care through a coordinated and collaborative effort (Fromer et.al, 2011). In order to reduce the potential risk of hospital readmissions, it is necessary to develop a strategy that promotes self-management in the home environment, identifies a workflow format to address COPD at its different stages so that all areas are considered, and that identifies a method under which there is likely to be a positive and meaningful approach to CUPD that will have the greatest possible impact on these patients over time (Fromer et.al, 2011). Although this article does not address a specific research question, it provides further evidence of the need for additional support for COPD patients at the maintenance stage rather than at the acute stage of the disease (Fromer et.al, 2011). Furthermore, it provides additional knowledge regarding the implementation of a collaborative approach to chronic care that will have a lasting impact on patient care quality for the foreseeable future (Fromer et.al, 2011).

A study by Cramm & Nieboer (2013) examines the importance of high-quality chronic care delivery in the treatment of patients with chronic illness and whether or not this process has a lasting impact on the experiences of these patients in managing their disease in the best possible manner. A longitudinal design strategy represents a means of improving the understanding of how chronic diseases are treated and the steps that are required to address these conditions effectively and in a timely manner to improve quality of life for patients (Cramm & Nieboer, 2013). It is important to evaluate the specific conditions under which patients might receive improved quality of care that will have a lasting impact on their wellbeing throughout the course of their lives, and how to consider the overall impact of chronic disease on quality of life, using disease management programs as a guide (Cramm & Nieboer, 2013). It is necessary to identify the conditions under which patients might effectively respond to treatments and under which they are able to achieve improved quality of life using different methods of care delivery (Cramm & Nieboer, 2013). In this study, patient PACIC scores improved over a period of time when they received the appropriate level of care and treatment and their experiences were also more positive during this period, thereby creating opportunities to examine the importance of effective chronic disease management in addressing these conditions more effectively with less of an emphasis on acute symptoms and a greater emphasis on long-term management and stability (Cramm & Nieboer, 2013). This study provides additional support and evidence that indicates the need for chronic disease management models in the treatment of COPD so that there is a greater level of consistency in managing the disease (Cramm & Nieboer, 2013).

A study by Jones et.al (2012) addresses the significance of COPD and the treatment of patients in primary care settings, using a cross-sectional design to demonstrate the importance of health-related quality of life (HRQL) for these patients. The study notes the following: “The main aim of this paper is to describe the factors associated with the assessment by PCPs of COPD severity. The complete HEED population, who had a confirmed PCP diagnosis of COPD without applying strict spirometry criteria, was evaluated. This real-life approach was intended to reflect how PCPs manage their COPD patients in everyday practice” (Jones et.al, 2012, p. 2). This is an important indicator of the treatment methods that are typically utilized and how they have a lasting impact on patient care and related outcomes, while also considering the value of strategies to improve primary care practice as related to COPD evaluation and treatment (Jones et.al, 2012). Most importantly, patients in primary care settings must receive improved attention and care as related to COPD because outcomes and quality of life in many cases are generally poor and inadequate (Jones et.al, 2012). Under these conditions, it is necessary to identify areas whereby patients might be able to receive the desired level of treatment that will improve quality of life and enable patients to be more successful in managing their routine daily activities without experiencing as many acute exacerbations of the disease (Jones et.al, 2012). This represents an opportunity to examine the overall impact of chronic disease management and the decision-making made by primary care providers in regards to COPD so that patients receive the best possible care and treatment on a consistent basis (Jones et.al, 2012). This study provides further evidence that chronic disease models of care must be implemented relative to COPD because of the nature of the disease, the risk of the symptoms that are likely to occur, and the overall impact of the disease on quality of life. It is important to identify the methods that are likely to be most effective in this area and that will demonstrate how to have a positive influence on quality of life for patients who struggle with COPD on a daily basis in order to prevent as many acute exacerbations of the disease as possible.

Finally, a study by Lemmens et.al (2011) addresses the significance of prior evidence as related to chronic disease management methods for COPD patients. Most importantly, this study notes the following: “The common aim of these programmes is to improve processes and outcomes of care while making a more efficient use of scarce health care resources, or even generate cost savings. Notwithstanding the awareness among policy makers, payers, professionals and patients of the importance of chronic care management, insight into the effectiveness of the various approaches is limited” (Lemmens et.al, 2011, p. 2). Under these conditions, it is important to identify research-based methods that will provide the best possible opportunity to improve patient outcomes and that will examine patients at differnet stages of the disease (Lemmens et.al, 2011). The study employed a meta-analysis method in order to determine how COPD might be impacted by chronic disease management models and how to best overcome the conditions under which chronic care might be most effective in treating patients at the desired level to promote consistency and greater quality of care (Lemmens et.al, 2011). The study aimed to identify areas where quality of life was improved and hospitalizations were decreased, given the conditions under which chronic care management was implemented, thereby increasing the potential for effective care and treatment for this patient population as the disease progresses (Lemmens et.al, 2011). There must be considerable attention paid to the overall development of new ideas and strategies to accommodate patients and to exercise improvements in quality of care that will effectively translate into improved quality of life for these patients over time (Lemmens et.al, 2011). This article supports the continued growth and development of new ideas and approaches to effectively manage the daily issues surrounding COPD and to further evaluate other areas where there must be additional emphasis placed upon patient care quality that will effectively translate into improved quality of life for these patients (Lemmens et.al, 2011).

Conclusion

COPD is a complex and multifaceted disease that requires ongoing care and treatment in order to accomplish the intended objectives to improve quality of life for affected patients. The rate of acute exacerbations is quite high in some patients; therefore, additional methods must be considered that will contribute to the improvement of quality of life for these patients across a variety of age groups and demographics. The implementation of the Chronic Disease Model has been largely successful in other settings; therefore, it must be examined for its potential advantages for patients who are at risk of experiencing COPD symptoms throughout their daily lives. It is necessary to determine how to implement a model of this nature so that patients receive the best possible benefits, and this is best accomplished by using a series of methods that will positively impact patients and that will enable them to receive high quality care and treatment, not only at the acute exacerbations stage, but also as part of a long-term maintenance strategy for these patients. Most importantly, patients must receive greater attention and focus on a continuous basis in order to prevent exacerbations from limiting their quality of life and in order to prevent further decline in quality of life.

It is believed that these factors are likely to enable patients to experience greater quality of life and to be effective in meeting the needs of the disease in a comprehensive manner. These conditions must be examined more closely and must demonstrate the importance of improving outcomes and quality of life for COPD patients, using existing methods that have been proven successful and appropriate in managing the condition on a maintenance basis that will also satisfy the long-term objectives of care, treatment, and maintenance of the condition and its symptoms. It is imperative that these conditions are effectively evaluated in order to accomplish successful patient care results and to reduce the number of hospitalizations, particularly recurrent hospitalizations, which occur as a result of COPD symptoms and acute exacerbations. The quality of life of this patient population is largely contingent upon these resources and requires further consideration and evaluation of these patients in order to accomplish the intended objectives in a reasonable and practical manner.

References

Cramm, J. M., & Nieboer, A. P. (2012). The chronic care model: congruency and predictors among patients with cardiovascular diseases and chronic obstructive pulmonary disease in the Netherlands. BMC health services research, 12(1), 242.

Cramm, J. M., & Nieboer, A. P. (2013). High-quality chronic care delivery improves experiences of chronically ill patients receiving care. International journal for quality in health care, mzt065.

Cramm, J. M., Rutten-Van Mölken, M. P., & Nieboer, A. P. (2012). The potential for integrated care programmes to improve quality of care as assessed by patients with COPD: early results from a real-world implementation study in The Netherlands. International journal of integrated care, 12.

Fromer, L. (2011). Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes. International journal of chronic obstructive pulmonary disease, 6, 605.

Jones, P. W., Brusselle, G., Dal Negro, R. W., Ferrer, M., Kardos, P., Levy, M. L., … & Banik, (2012). Patient-centred assessment of COPD in primary care: experience from a cross-sectional study of health-related quality of life in Europe.Prim Care Respir J,21(3), 329-336.

Lemmens, K. M., Lemmens, L. C., Boom, J. H., Drewes, H. W., Meeuwissen, J. A., Steuten, L. M., … & Baan, C. A. (2013). Chronic care management for patients with COPD: a critical review of available evidence. Journal of evaluation in clinical practice, 19(5), 734-752.