Chronic Illness Care: Principles and Practice

Introduction
Contents
Contributors
Part I: Individual Influences on Chronic Illness
1: Genetic Contributions and Personalized Medicine
Role of Genetics in Chronic Disease
Gene–Drug Considerations for Chronic Disease
Autoimmune Disorders
Cancer
Infectious Diseases
Psychiatric and Neurologic Conditions
Chronic Pain
Cardiovascular Disease
Diabetes Mellitus
Implementation of Personalized Medicine
Barriers to Implementation
Pharmacogenomic Implementation Tools
Implementation Strategies
Future of Personalized Medicine
References
2: Obesity and Chronic Disease
Prevalence and Impact
Defining Obesity
Obesity as a Chronic Disease
Obesity and Comorbid Conditions
Obesity and COVID-19
Health Disparities in Obesity
Treating Obesity
Approach to Patient
Nutrition and Dietary Treatments
Physical Activity for Weight Loss
Weight Loss Medications
Metabolic Surgery
Future Directions
References
3: Promoting Physical Activity
Relationship of Reduced Physical Activity and Chronic Disease
Aging and Exercise
Frailty
Obesity and Chronic Disease
Primary Prevention of Chronic Disease
Secondary Prevention of Chronic Disease
Diabetes Mellitus
Cardiovascular Diseases
Chronic Obstructive Pulmonary Disease
Osteoporosis
Osteoarthritis
Promoting Physical Activity
Exercise as a Vital Sign
The Exercise Prescription
Defining Physical Activity and Exercise
Recommendations for Adults
Recommendations for Older Adults
Recommendations for Obese Patients
Recommendations for Children
Community and Clinic Initiatives
Future Trends
References
4: Tobacco Use and Dependence
Introduction
Tobacco Use and Chronic Disease
Tobacco Use as a Chronic Disease
Impact on Other Chronic Diseases
Types of Tobacco Products
Smoked (Combustibles)
Smokeless (Non-combustibles)
E-Cigarettes (Vapes) and Heated Tobacco Products
Second- and Thirdhand Smoke Exposure
Benefits of Cessation in Patient Populations
Asymptomatic Patients and Disease Prevention
Cardiovascular Disease
Diabetes
Chronic Obstructive Pulmonary Disease
Asthma
Cancer
HIV/AIDS
Mental Health and Substance Use
Inpatients
The Chronic Care Model and Tobacco Dependence
A Comprehensive Approach
Team Approach
Family and Social Support
Public Health Interventions
Emotional Support
The 5As Model for Tobacco Cessation
Ask
Advise
Assess
Assist
Cutting-Down-to-Quit (Nicotine Fading)
Behavioral Counseling
Pharmacotherapy
Arrange
Telehealth
Population Health and the Health Care System
Quality Improvement
Insurance Changes
Future Directions
Social Media, mHealth, and eHealth
New Pharmacotherapies
E-Cigarettes for Quitting Cigarettes
Behavioral Therapies
Genetics
Adolescents and Young Adults
Prenatal Treatment
Education to Health Care Team Members
References
5: Chronic Disease Self-Management
Introduction
Historical Developments
Principles of Self-Management
Limitations of Physician-Directed Care
Chronic Care Model
Empowerment
Shared Decision-Making
Health Literacy
Practicalities of Self-Management
Managing Chronic Disease at Home
Technological Advancements
Peer Support
Case Management/Population Health Services
Future Directions
References
6: Alcohol and Drug Use Disorders
Introduction
Substance Use Disorders and Chronic Conditions
Screening Approaches and Diagnostic Criteria
Treatment of Substance Use Disorders
Barriers to Treatment
Harm Reduction
Pharmacotherapy
Psychosocial Interventions
Peer-Based Recovery
Monitoring Treatment Effectiveness
Integrating Treatment into Primary Care
Telehealth for Substance Use Disorder
Future Directions
References
Part II: Family, Social, and Community Support
7: Family and Other Caregivers
Introduction
Demographics of Caregivers
The Effects of Caregiving
Positive Effects of Caregiving
Health Consequences of Caregiving
Risk Factors for Caregiver Burden
Physical Consequences
Psychological Consequences
Financial Consequences
Specific Conditions and Caregiving
Chronically Ill Children
Dementia
Mental Health Disorders
Physical Disabilities
Caregiving During the COVID-19 Pandemic
End-of-Life Care
Evaluating and Supporting Caregivers
Caregivers as Invisible Patients
Interventions
Public Policy and Caregiving
Cultural Aspects of Caregiving
Future Directions
References
8: Domestic Violence, Abuse, and Neglect
Introduction
General Guidelines
Intimate Partner Violence (IPV)
Child Abuse
Toxic Stress, Child Maltreatment, and IPV
Elder Mistreatment
Patient Evaluation
Suspected IPV
Suspected Child Abuse
Physical Abuse
Skin Injuries
Fractures
Abdominal Injuries
Head Injuries
Suspected Neglect
Sexual Abuse
Suspected Elder Mistreatment
Management Strategies
Mandated Reporting
Trauma-Informed Care
Approaching Intimate Partner Violence
Approach to Child Maltreatment
Enhanced Health Care Needs of Maltreated Children
Approach to Elder Mistreatment
Prevention of Family Violence
Future Directions
References
9: Peer Support
Introduction
Understanding Peer Support
Foundations of Peer Support
Evidence Base of Peer Support
Implementation and Dissemination Approaches
Engaging the Hardly Reached
Reaching Populations
Addressing Social Determinants of Health
Reaching Out for Behavioral Health
Cultural Considerations: Adaptable Standardization in China
Peer Support Applications in Primary Care
Organizational and Fiscal Considerations
Peer Support and Health Information Technologies
Peer Support Workforce
Future Directions
References
10: Government Agencies and Community Organizations
Introduction
Government Agencies
US Department of Health and Human Services (HHS)
Centers for Medicare and Medicaid Services (CMS)
Centers for Disease Control and Prevention (CDC)
Administration for Community Living
Administration for Children and Families (ACF)
Health Resources and Services Administration (HRSA)
Substance Abuse and Mental Health Services Administration (SAMHSA)
US Department of Agriculture (USDA)
Supplemental Nutrition Assistance Program (SNAP)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Child Nutrition Programs
State and Local Health Agencies
Non-government Organizations
American Heart Association (AHA)
American Cancer Society (ACS)
American Diabetes Association (ADA)
Alzheimer’s Association
Legal Aid
National Alliance on Mental Illness (NAMI)
United Way
Faith-Based Organizations
Engaging with Community Organizations
Primary Care Practice Connection to Community-Based Organizations
Cross-sector Community Partnership Models to Address Health Equity and Social Determinants of Health
The Emerging Role of Payers in Clinical/Community Partnerships
Future Directions
References
Part III: Providing Chronic Illness Care
11: Screening and Secondary Prevention
Introduction
Principles That Inform Screening
Sensitivity and Specificity
Positive and Negative Predictive Value
The Effect of Disease Prevalence
Levels of Screening
Population-Based Screening
Individual Screening
Opportunistic Screening
Benefits and Risks of Screening
Overdiagnosis and Overtreatment
Implementing Effective Screening
Evidence Base of Screening
Screening with Strong Evidence (A, B): Lung Cancer
Potential Benefits
Potential Harms
Implementation
Screening with Shared Decision Making (B, C): Breast Cancer and Mammography
Potential Benefits
Potential Harms
Implementation
Screening with Risk of Harm (D): Asymptomatic Carotid Artery Stenosis
Potential Harms
Implementation
Secondary Prevention
Social Determinants of Health
Future Directions
References
12: Vaccines and Immunization
Introduction
Vaccine Classes
Live Attenuated Vaccines
Inactivated Vaccines
Passive Immunization
Key Concepts
Cocooning
Community Immunity
Immunization Recommendations
United States
Europe, the United Kingdom, and Low- and Middle-Income Countries
Considerations for Chronic Illness and Associated Conditions
Vaccination of the Immunocompromised Host
General Principles
Primary (Congenital) Immunodeficiencies
Patients on Immunosuppressive Therapy
High-Level Immunosuppression
Low-Level Immunosuppression
Adults with HIV
Children with HIV
Asplenia or Sickle Cell Disease
Patients with Cancer Receiving Chemotherapy
Hematopoietic Stem-Cell Transplant (HSCT) Recipients
Solid Organ Transplant (SOT) Recipients
Immunocompromised Children with Chronic Illness
Diabetes Mellitus
Chronic Kidney Disease (CKD)
Pulmonary Disease
Chronic Liver Disease
Pregnancy
Tobacco Use Disorder
Children with Cardiovascular Disease
Obesity
Neurodegenerative and Neuromuscular Disease
Strategies to Promote Vaccine Uptake
Communication Approaches
Missed Opportunities
Provider Reminders
Patient Reminders and Recall Systems
Data-Informed Feedback
Future Directions
References
13: Medication Management and Treatment Adherence
Introduction
Understanding Medication Management
Medication-Related Problems (MRPs)
Effective Medication Management
Medication Reconciliation
Comprehensive Medication Review
Patient Counseling
Assessment Tools for Non-adherence and Health Literacy
Non-adherence
Health Literacy
Communication Strategies
Strategies to Promote Treatment Adherence and Medication Management
Future Directions
References
14: Patient-Provider Communication and Interactions
Introduction
Communication in the Provider-Patient Dyad
Goals of Patient-Provider Interactions
Communication Approaches and Techniques
Shared Decision-Making
Acknowledging, Bridging, and Embracing Language, Identity, and Culture
Navigating Language Differences
Cultural Competence and Humility
Acknowledging Structural Racism
Intersectionality, Positionality, and Implicit Bias
Communication in Chronic Care Models
Healthcare Team Communication
Group Care Models
Specific Challenges and Special Situations
Working with Family Members, Advocates, and Other Proxies
Giving Bad News
Crucial Conversations and Conflict Management
Health Information Technology
Future Directions
References
15: Ambulatory Primary Care and Urgent Care
Defining Ambulatory Care, Ambulatory Primary Care, and Urgent Care
The Ecology of Medical Care
Ambulatory Primary Care and Chronic Disease
Chronic Disease Care Quality in Ambulatory Primary Care
Ambulatory Primary Care Chronic Care Models
Starfield’s 4 C’s
Wagner’s Chronic Care Model
Patient-Centered Medical Home
Direct Primary Care
Enhanced Team-Based Ambulatory Primary Care Chronic Illness Care
Urgent Care
Acute Illnesses Superimposed on Chronic Disease in Urgent Care
Choosing Urgent Care
Coordinating Care with Primary Care Physicians
Addressing Chronic Disease Metrics in Urgent Care
Transitional Care
Organizing Urgent Care
Access and Time Challenges in Ambulatory Care
Payment Models and Financing
Fee for Service
Capitation
Value-Based Payments
Direct Primary Care
Telehealth and Virtual Care
Impact of COVID-19 Pandemic on Ambulatory Care
Future Directions
Teaching and Training in the Ambulatory Setting
Payment Reform
Research in Primary Care and Urgent Care
References
16: Virtual Care
Introduction
Principles and Concepts of Telehealth
Limitations of Telehealth
History of Telehealth
Impact of COVID-19 Pandemic
Factors Influencing Telehealth Growth
Organization of Telehealth Services
Primary Care
Urgent Care
Specialty Care
Acute Hospital Care
Post-acute Care
Management and Operations of Telehealth Services
Information Technology (IT) Infrastructure
System Oversight and Workflows
Legal and Compliance Considerations
Future Directions
References
17: Acute Hospital Care
Introduction
Pre-admission Evaluation and Assessment
History and Physical Examination
Collateral Information
Medication Reconciliation
Advance Care Planning
Admission
Level of Care
Admitting Orders
Preventing Iatrogenic Errors and Nosocomial Infections
Laboratory and Diagnostic Testing
Medication Management
Anticipated Length of Stay and Discharge Needs
Acute Hospital Management
Antibiotic and Medication Stewardship
Changes in Patient Status
Care Teams
Quality Improvement and Patient Safety
Advance Care Planning
Discharge
Post-discharge Location
Medication Reconciliation
Patient Education
Discharge Summary
Transitional Care
Special Considerations
COVID-19 Pandemic
Behavioral Health
Patients with Limited Decision-Making Capacity
Future Directions
References
18: Emergency Care
Introduction
Organization of Emergency Care Services
Processes of Emergency Care
In the Field/Pre-arrival
Arrival at the Emergency Department
Assessment and Treatment
Disposition
Quality of Care
Special Considerations
Older Adults
Pain Management
Future Directions
References
19: Post-Acute and Long-Term Care
Introduction
Short-Term or Post-Acute Care
Common Conditions in Acute Rehabilitation
Stroke
Hip Fracture
Total Joint Arthroplasty
Acute Rehabilitation Sites of Care
Acute Inpatient Rehabilitation
Long-Term Acute Care Hospitals
Skilled Nursing Facility
Transitions Across Care Sites During Rehabilitation
Long-Term Care
Quality of Care
State and Federal Government Oversight
Common Conditions in Long-Term Care
Financing of Acute Rehabilitation and Long-Term Care
Financing of Acute Rehabilitation
Financing of Long-Term Care
Multidisciplinary Care Team
Racial Disparities in Long-Term Care
COVID-19 and Infection Prevention
Future Directions
References
20: Home- and Community-Based Care
Introduction
Financing Community-Based Long-Term Care
Emerging Payment Models
Home-Based Clinical Care
Home Services by Allied Health Professionals
Home-Based Medical Care by Physicians and Advance Practice Providers
Home-Based Primary Care
Consultative Visits and Specialty Care
Palliative Care
Hospital-at-Home
Evaluation and Assessment in the Home
Telehealth and Virtual Care
Nonresidential Community-Based Care
Home-Based Personal Care Services
Area Agencies on Aging and Senior Centers
Adult Day Services Centers
Programs of All-Inclusive Care for the Elderly
Aging in Place and the Villages Movement
Technologies to Facilitate Aging in Place
Residential Options for Community-Based Care
Senior Housing
Assisted Living
Adult Foster Care
Medical Foster Home Care
The Green House Model
Continuing Care Retirement Communities
Principles of Care of the Community-Dwelling Older Patient
Coordinating Care Across Settings of Care
Administrative and Regulatory Issues
Home- and Community-Based Services and Health Equity
Disparities in Access
Strategies for Improving Equity
Conclusion
References
21: End-of-Life Care
Chronic Disease and the Change in How People Die
Birth of Modern Hospice and Palliative Care Movement
Decisions and Communication
Advance Care Planning
Decision Aids and Documentation
Ethical Issues
Withdrawing, Withholding, and Refusing Care
Physician Assisted Death
Palliative Sedation
Quality of Care
Financial Reimbursement and Cost Savings
Provision and Place of End-of-Life Care
Home
Hospitals
Nursing Homes
Special Populations
Dementia
People with Intellectual Disabilities or Mental Illness
Intellectual Disability
Mental Illness
Children
Future Directions
Changing the Focus
Racial Disparities and Cultural Diversity
Value-Based Payment Models
Workforce and Wellbeing
References
22: Special Population: Children and Adolescents
Definitions and Demographics
Sites of Care for Children with Chronic Illness
Hospitals
The Outpatient Medical Home
Home
Schools
Community
Quality of Care and Population Health
Health Disparities in Care and Research
COVID-19 and Chronic Illness in Children
Medicaid and Financing
Impact of Chronic Disease on Children
Growth and Development
Education
Family Role and Socialization
Psychological Consequences
Transition to Adulthood
Future Directions
References
23: Special Population: Older Adults
Epidemiology of Chronic Disease in Older Adults
Ageism
The Impact of COVID-19 on Chronically Ill Older Adults
Social Determinants of Health for Older Adults
Health Literacy
Social Support and Access to Community Resources
Elder Abuse
Access to Food
Health Disparities
Objectives of Care in Older Adults with Chronic Illness
Quality of Life
Function
Life Expectancy and Prognosis
Advance Care Planning
Systems of Support
Each Individual Is Unique
Geriatric Syndromes
Organization of Care for Older Adults with Chronic Illness
Hospital
Care Transitions
Nursing Home Care
Outpatient and Community Care
Telehealth
Future Directions
References
24: Special Population: Adults with Intellectual and Developmental Disabilities
Introduction
Clinical Assessment and Management
General Principles
Medical Conditions and Disorders
Preventive Services
Managing Behavioral and Mental Health Conditions
Diagnosing Psychiatric Conditions and Mental Health Disorders
Managing Acute Problem Behaviors
Use of Psychotropic Medications
The Impact of COVID-19 on Individuals with IDD
Organization and Delivery of Healthcare Services
Final Comments
References
25: Special Population: Adults with Severe and Persistent Mental Health Disorders
Introduction
The Spectrum of Serious Mental Illness
Schizophrenia
Schizoaffective Disorder
Bipolar Disorder
Medical Comorbidities
Cardiovascular Disease
Metabolic Disorders
Tobacco Use Disorder
Alcohol and Substance Use Disorder
Intellectual and Developmental Disability
Traumatic Brain Injury
Dementia and Cognitive Impairment
Caring for Individuals with Serious Mental Illness
Management of Schizophrenia
Management of Schizoaffective Disorder
Management of Bipolar Disorder
Nonpharmacologic Treatment
Psychiatric Emergencies
Healthcare Models and Programs
Assertive Community Treatment Teams
Community Mental Health Centers
Psychiatric Residential Treatment Facilities
Psychiatric Hospitals
Peer Support Specialists
Emerging Service Models
Future Directions
References
26: Special Population: LGBTQ Community
Introduction
Definitions and Demographics
Stigma, Discrimination, and Minority Stress
Organizing Inclusive Chronic Care
Health Care System Considerations
Clinic and Practice Considerations
Cultural Humility and Inclusive Practices
Patient Care for Chronic Conditions
Psychosocial Factors
Mental Health
Suicide
Substance Use Disorders
Sexual Health and High-Risk Sexual Experiences
Cancer Screening
Gender Affirming Therapy
Youth and Emerging Adults
Older Adults
Future Directions
References
27: Special Population: Care of Incarcerated Persons
Introduction
Health Services During Incarceration
Legal Precedents
Organization of Care
Providing Care to Persons Who Are Incarcerated
Clinical Services
Mental Health
Substance Use Disorders
Special Conditions
Human Immunodeficiency Virus
Hepatitis C
Pregnancy
Quality of Care
Post-Release and Reentry
Programs to Promote Reentry
Future Directions
References
28: Special Population: Care of Immigrants and Refugees
Introduction
Populations and Terminology
Processes of Immigration and Resettlement
International Policies and Governing Bodies
US Refugee Resettlement Processes
Domestic Medical Examination
Adjustment of Status and Citizenship Trajectory
Social and Community Issues
Stages of Migration
Changes in Family Structure
Impact of Poverty and Limited Resources
Differences in Understanding of Health and Health Literacy
Refugees and Chronic Disease
Infectious Disease
Tuberculosis
Chronic Hepatitis and HIV
Vaccine-Preventable Diseases
Intestinal Parasites
Mental Health Issues
Causes and Social Determinants of Mental Disorders
Mental Health Screening
Cultural Factors
Treatment Considerations
Framework for Refugee Primary Care
References
Resources/Websites
29: Special Population: COVID-Associated Chronic Conditions
Introduction
Defining Post-COVID Conditions
Symptoms, Natural History, and Risk Factors
Pathophysiology
Management Principles
History and Symptom Review
Manage Comorbid Conditions
Evaluate Impact on Functioning and Activities
Consider Psychosocial Stressors
Utilize a Focused Medical Evaluation
Care of Symptoms Associated with Post-COVID Conditions
Fatigue
Return to Activity Program
Energy Conservation Techniques
Healthy Dietary Approaches
Management of Comorbid Conditions
Respiratory Symptoms
Cardiovascular Symptoms
Special Consideration: Postural Orthostatic Tachycardia Syndrome (POTS) Dysautonomia
Cognitive Symptoms
Health Care Service Models
Future Directions
References
30: Special Population: Care of Cancer Survivors
Introduction
Background
Epidemiology of Cancer Survivorship
Prevalence
Mortality
Functional Status and Quality of Life
Multimorbidity
Cancer Survivor Syndromes
Cancer Survivorship Care
Models and Guidelines
Gaps in Clinical Practice
Advancing Survivorship Care
Chronic Illness Care Models
Self-Management, Peer, and Family Support
Health Care System Considerations
Care Coordination and Navigation
Patient Reported Outcomes
Digital Health
Future Directions
References
31: Special Populations: Care of Military Veterans
Introduction
Veteran Population
Veteran Care
History
Veterans Health Administration
Eligibility and Cost
Veteran-Specific Chronic Health Issues
Musculoskeletal
Traumatic Brain Injury
Post-traumatic Stress Disorder
Moral Injury
Depression
Substance Abuse Disorder
Suicide
Chronic Pain
Women’s Health Care
Military Sexual Trauma
Occupational Exposures
Hearing and Tinnitus
Airborne Hazards
Agent Orange
Social Issues
Health Disparities Among Veterans
Homelessness
Non-health Care Benefits to Veterans
Future Directions
References
32: Special Populations: Care of Persons Experiencing Homelessness
Introduction
Characteristics of Persons Experiencing Homelessness
The Mental and Physical Health Hazards of Experiencing Homelessness
Mental Illness and Substance Use Disorders
Infectious Disease
Chronic Medical Conditions
Screening for Vulnerably Housed and Persons Experiencing Homelessness
Providing Integrated Care to Persons Experiencing Homelessness
Housing First and Associated Strategies
Medical Respite and Recuperative Care
Outreach and Engagement
Drop-In Centers
COVID Mitigation Strategies
Final Comments
References
Part IV: Organizational Frameworks for Chronic Illness Care
33: Integrated Behavioral Health Care
Introduction
Meeting the Need in Primary Care
Interplay of Emotional and Physical Health
Reducing Stigma in Mental Health
Health Care Disparities and Access
Improving Continuity of Care
Improving Outcomes at Reduced Cost
Models of Integrated Behavioral Health Care
Co-located Behavioral Health
Primary Care Behavioral Health
Screening, Brief Intervention, and Referral to Treatment
The Collaborative Care Management Model
Implementation Strategies and Considerations
Mission and Vision
Staffing and Training
Workflow
Workspace Design
Schedules
Communication
Practice Improvement
Future Directions and Trends
Summary
References
34: Transitions of Care
Introduction
Definition and History of Transitions of Care
Programs in Transitions of Care
Finance and Transitions of Care
Effective Transitions of Care
Anticipating and Preventing Reasons for Readmission
Pre-discharge Transitional Care Management
Patient Education
Discharge Summary
Medications
Durable Medical Equipment
Transportation
Post-discharge Transitional Care Management
Phone Calls
Follow-Up Visits
Bridging Components of Transitional Care Management
Advance Care Planning
Interprofessional Approach to Transitions of Care
Physician and Advance Practice Provider Role
Nurse Role
Pharmacist Role
Social Worker Role
Medical Assistant Role
Physical and Occupational Therapist Roles
Family and Patient Role
Disparities in Transitions of Care
Racial and Ethnic Disparities
Language Barriers
Future Directions
References
35: Population Health
Introduction
Defining Population Health
Population Health Conceptual Models
Defining Care Management
Care Management Functions
Implementing Care Management
Information Technology
Future Directions
References
36: Artificial Intelligence, Machine Learning, and Natural Language Processing
Introduction
Definitions
Differences from Statistics
Historical Highlights
The Black Box Problem
Health Inequity
Applications to Chronic Illness Care
Individual Patient Applications
Home Applications
Healthcare Provider Applications
Practice Applications
Community Applications
Health Policy Applications
Health Equity Concerns
Future Directions
References
37: Health Information Technology
Introduction
From Paper to Electrons: An Historical Perspective of Health IT
Genesis and Evolution of Health IT for Chronic Disease Management
Crossing the Quality Chasm: Putting a Spotlight on the Healthcare System’s Failures
An Opportunity Through the 2008 Great Recession
Electronic Health Records (EHRs)
The Meaningful Use (MU) of EHRs
MU Objective #1: Electronic Capture of Health Information in a Standardized Format
MU Objective #2: Clinical Decision Support (CDS) Systems
MU Objective #3: Facilitate Quality Reporting of Care Processes and Patient Outcomes
MU Objective #4: Engage Patients in Their Care and Encourage Patient Self-Management
MU Objective #5: Facilitate Sharing of Patient Information Among Treating Providers
Effectiveness of Health IT in Chronic Disease Management
Population Health and Chronic Disease Management
Future Directions
References
38: Quality Improvement
Introduction
Movements and Initiatives Promoting Quality Improvement
Quality Enters Health Care
Patient-Centered Medical Home
Institute for Healthcare Improvement
Federal Government Enters Quality Improvement
Quality Improvement Principles
Quality Improvement Models and Frameworks
Deming Cycle/PDSA
Forming the Team
Setting Aims
Selecting Measures
Selecting, Testing, Implementing and Spreading Change
Six Sigma
Lean
Practice Level Quality Improvement
System Level Quality Improvement and Transformation
Change Management
Data Management
Collecting Data
Tracking Data
Analyzing and Interpreting Data
Acting on Data
Disseminating Data
Future Directions
References
39: Quality of Life and Patient-Centered Outcomes
Introduction
Defining Patient-Reported Outcomes
Clinical Applications of Patient-Reported Outcomes
Individual Level PRO Data
Screening
Treatment Monitoring
Facilitating Patient-Centered Care
Enhancing Disease Self-Management
Facilitating Communication in Multidisciplinary Care Teams
Population-Level PRO Data
Assisting in Decision-Making
Managing Population Health
Improving Quality of Care
Developmental Milestones in Patient-Reported Outcomes
Evidence Base of Patient-Reported Outcomes
Patient-Reported Outcomes in Chronic Illness Care
Challenges in Using Patient-Reported Outcomes
Future Directions
References
Part V: Social and Environmental Determinants of Chronic Illness
40: Social Determinants of Health
Introduction
Understanding Social Determinants
Social Determinants and Chronic Disease
Conceptual and Theoretical Frameworks
Lifestyle
Biomedical
Life Course
Fundamental Social Causes
Public Policy
Social Ecological
Addressing Social Determinants
Promoting Equity as a Value in Health Care
Collecting Patient Data on Social Risk Factors
Funding for Addressing Social Risk Factors
Health Care System Performance for Patients with Social Risk Factors
Health Literacy
Social Deprivation, Mental Health Disorders, and Comorbid Chronic Disease
Community-Level Action to Identify Social Patterns of Illness and Improve Outcomes
Health Policy
Positively Impacting Social Determinants
Capability: Addressing Social Determinants through Ethics, Measurement, and Action
Final Comments
References
41: Environmental Determinants of Health
Introduction
Estimating the Burden of Disease Attributable to Environmental Determinants
Method for Estimating the Environmental Burden of Disease
Current Estimates of the Environmental Burden of Disease
Outdoor Air Pollution
Indoor Air Pollution
Occupational Exposure to Environmental Pollutants
Water Pollution
Lead Exposure
Automobile-Centric Urban Designs
Climate Change
Addressing Environmental Risk Factors in Chronic Illness Care
Reporting Requirements for Environmental Diseases
References
42: Health Inequities and Structural Racism
Introduction
Key Concepts
Understanding Health Inequities and Disparities
National Institute of Minority Health and Health Disparities (NIMHD) Framework
Individual Level Factors
Interpersonal Factors
Community Level Factors
Food Insecurity
Housing Stability
Green Space
Social Connectedness
Societal Level Factors
Environment
Carceral System
Access to Health Services
Strategies to Mitigate and Reduce Health Disparities
Trauma-Informed Care
Addressing Unconscious (Implicit) Bias
Community Health Workers
Workforce Education and Training
Increasing Workforce Diversity
Future Directions
References
Part VI: Health Policy and Chronic Illness Care
43: Medicare
Introduction
Origins
Populations Served
Benefits
Expenditures and Financing
Medicare and the Affordable Care Act
Controlling Medicare Spending
Payment and Delivery Reform
Medicare and COVID-19
Medicare for All
Reforming Medicare
The Future of Medicare
References
44: Medicaid
Introduction
Historical Developments
Medicaid Eligibility, Covered Services, and Cost Sharing
Eligibility
Covered Services
Cost Sharing
Impact of Medicaid Expansion on Health Outcomes
Provider Payments
Delivery System
Financing
Medicaid Expenditures
Medicaid Waivers
Impact of Medicaid for Persons with Chronic Illnesses
Final Comments
References
45: Value-Based Care
Introduction
Historical Developments
Programs and Payment Models
Hospital Quality and Value Programs
Alternative Payment Models (APM’s)
Patient Attribution
Quality Model
Total Cost of Care Benchmarking
Financial Model
Accountable Care Organizations (ACOs)
Episode-Based Payment Models
Current State of Accountable Care
Future Directions
References
46: Health Care Workforce
Introduction
Defining the Health Care Workforce
Other Healthcare Practitioners
Workforce Planning for Chronic Care
Team-Based Care
Nurse Practitioners
Medical Assistants
Nursing Assistants
Registered Nurses
Pharmacists
Addressing Social and Behavioral Health Needs
Social Workers
Public Health Workers
Community Health Workers
Innovative Models
Health Care Financing for Chronic Care
Gaps in Training the Chronic Care Workforce
Training Mismatch
The Role of Compensation
Workforce Staffing Challenges
Organizational Staff Retention and Turnover
Burnout
Future Directions
References
Index