New approach to chronic disease care


Californians suffering from chronic disease -– anything from diabetes to hypertension -– are increasingly getting more attention from their doctors and other health care workers, who are using a new team-based approach to engage patients in managing their own health.

The goal is to keep people healthier and save money — for the patients and their families, the health care industry and the taxpayers.

Chronic diseases such as obesity, diabetes, cardiovascular disease, arthritis and asthma affect more than 16 million Californians – about 44% of the population – with half that number suffering from more than one chronic condition.

These diseases are becoming so widespread, in fact, that the American College of Physicians warns that meeting the needs of patients with chronic illness or impairment is the “single greatest challenge” facing organized medicine today.

“Dozens of surveys and audits have revealed that… chronically ill patients are not receiving effective therapy, have poor disease control, and are unhappy with their care,” the doctors’ group said in a recent report.

California health executives are catching on, and several new initiatives show promising signs of shifting a reactive healthcare system to a pro-active one.

“Team Up For Health” (TUFH) is a pilot program that joins patients and their healthcare advocates with physician teams to broadly expand the care given to sufferers of chronic disease – in personnel and time.

Sponsored by the California HealthCare Foundation with six pilot participants, the initiative centers on “team-based care” — better communication between doctors and patients – and a support model that extends long before and after medical appointments.

“Fifteen-minute appointments, four to six times a year with a physician, is inadequate for managing a chronic disease,” admits Dr. Samer Assaf, who implemented TUFH for the Sharp Rees-Stealy Medical Group in San Diego.

Using these principles, the medical group’s Genesee location now provides a list of scheduled patients with chronic conditions to each of its care teams. Teams review the list and devise “active patient monitoring” which goes far beyond the actual doctor’s visit and extends to pre- and post-visit care.

Team members ensure all tests are done, and call patients to remind them to bring in medicines or medical logs (such as blood sugar). Patients are also encouraged to engage a friend or family member who becomes actively involved in treatment.

Afterwards, a staff member calls the patient to follow up, ask what the patient needs, or offer advice.

“It’s all about making that visit as productive as possible,” says Dr. Jerry Penso, the medical group’s director for Continuum of Care.

A team of patient advisors join medical staff during meetings to offer feedback from a patient perspective.

“We go to their meetings and participate as if we were staff,” says patient advisor Ross Adams, 50, who suffers from several chronic conditions.

Penso says the objective is to involve patients in their own care. “Self-management,” he says, invests patients more heavily in the healing process, and produces better outcomes.

“We’re trying to create a really strong bond between patients with chronic disease and their healthcare team,” says Penso. “And the bond has to be based on a really trusting relationship.”

Doctors and nurses are also trained to communicate better: to listen, show empathy, ask open-ended questions and – for many doctors – use a less paternalistic attitude.

The project “has transformed the way I practice medicine,” says Assaf. “I realized that I was very directive and prescriptive, and I followed a familiar script for every patient with the same condition regardless of their level of readiness, activation or motivation. It had been all about my agenda.”

Adams, an Assaf patient, agrees. “I think he was a pretty good communicator prior to Team Up for Health,” he said. “But I’ve noticed how much more open-minded he has become as far as what patients have to say – not just me but other patients.”

Results of the pilot program are promising, including a 6% increase in achieving LDL cholesterol goals, a 15% increase in patients contacting a chronic illness support group, and vast improvement in self-management of care and overall support.

At the center of most chronic disease management programs is the Chronic Care Model developed by the MacColl Institute for Healthcare Innovation in Seattle, Washington.

“Most of our medical students are choosing careers other than primary care, which is of course where most chronic illness care is taking place,” says Dr. Ed Wagner, director of the institute.

From 2006 to 2008 Wagner worked with nine California academic medical centers to revamp their residency programs and sharpen their focus on chronic disease. The goal of the collaboration was to retain doctors in California, and change the prevailing treatment model from reactive to preventive.

Three other allies in the battle against chronic disease include quality ratings for health providers, electronic medical records (EMRs), and chronic disease registries. While EMRs are quickly becoming standardized, chronic care sorely lacks a centralized registry.

“That is a problem,” says Liz Helms, chair of the California Chronic Care Coalition. “Collecting data (from medical providers) is a major challenge… (sharing) this type of data could be utilized to improve quality for ethnically diverse populations, better manage chronic conditions and serve as a basis for the paradigm shift of our system of healthcare.”

In far north Humboldt County, published quality ratings for doctors have forced medical providers to streamline their efficiency and become more responsive to patients.

The Community Health Alliance of Humboldt – Del Norte, Inc. now publishes quality ratings for local health providers on its website. The ratings include prevention, diabetes care, cost effectiveness, and overall experiences.

Laura McEwen, project director for the alliance’s Aligning Forces for Quality initiative, says the organization has collected quality data for many years, but only recently began making it public.

“It’s a whole new ballgame when you do them publicly,” says McEwen. “The physicians feel more vulnerable.”

McEwen said she expected the ratings to be “a catalyst for consumers to step up and take notice.” Surprisingly, she found most patients have no idea there are differences in provider quality.

Instead, the real change has been with the providers themselves – from the inside. Offices have become more efficient and engaged.

“It really revitalized the way people go to work,” she said. “Now the medical assistant says ‘Hey I’m part of this team. I just saved a life.’”

An ambitious state initiative to combat chronic disease is currently underway that targets all of the state’s 20 million managed care patients.

The Department of Managed Health Care kicked off the Right Care Initiative in early 2008, targeting two chronic conditions statewide: cardiovascular disease and diabetes, with special emphasis on reducing hypertension, heart attack and stroke. (The initiative also addresses hospital-acquired infections.)

California’s quality scores for chronic disease are statistically poor compared to the best health plans across the nation, said Hattie Rees Hanley, program director for the initiative. Efforts to reduce blood pressure and LDL cholesterol “rank substantially below those of other states” according to a program brief.

Target goals of the initiative are to control the symptoms of 70% of patients with hypertension, cardiovascular disease, and diabetes.


The answer is deceptively simple: get doctors to prescribe known and effective medication bundles for high blood pressure and heart disease.

By following through on this simple procedure “we’ll see about a 60% reduction in heart attack and stroke,” said Hattie Rees Hanley, the Right Care Initiative’s project director. “It’s really strokes and heart attacks that kills most diabetics.”

Why aren’t doctors following this simple protocol today? “That’s the million dollar question,” says Handley.

Last year the initiative received additional funding from the National Institutes of Health to spotlight San Diego’s chronic care efforts.

This came with some lofty goals, according to Dr. Anthony DeMaria, founding director of the Sulpizio Family Cardiovascular Center at UC San Diego.

“We could dramatically reduce the number of heart attacks and strokes,” says DeMaria, “and set an audacious goal of trying to enlist the involvement of everybody in San Diego.”

One of the state’s broadest attempts at mitigating chronic disease began in 2006, when the California Improvement Network was created by the non-profit California HealthCare Foundation to address chronic diseases. Fusing eight public and private healthcare organizations under one umbrella to share “best practices” ranging from prevention to efficiency, seven reported reductions in chronic disease during the study period from 2007-2009.

In one example, a unit within the Los Angeles County Department of Health Services developed an online registry for managing patients with congestive heart failure, diabetes, and asthma. The county’s Clinical Resource Management team found it difficult, however, to convince primary care providers that the online registry was useful. After adding a medication tracking system, physicians eventually began using the registry on a regular basis.

The California Improvement Network was resurrected this February and now includes 14 members. At quarterly meetings, members share “best practices” for targeting chronic disease.

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