A new model of care pathways for reorganization of chronic care

The rise of chronic diseases represents major challenges for actual health-care systems. Most developed countries are facing growing health-care costs due to an aging population in which 70% of health-care expenses are related to chronic diseases, and the current fragile economic climate may progressively limit resources available to health-care systems. Another challenge lies in the actual organization of health-care delivery systems. Current health-care delivery systems are often unable to meet the complex needs of chronically ill patients for several reasons. Firstly, health care is traditionally focused on acute care management and short-term goals. Secondly, fragmented delivery of health and social services, including disconnection of primary and secondary care, is an acknowledged problem in many health-care systems. Thirdly, too often chronic care approaches feature an uninformed, passive patient interacting with a poorly coordinated team of health professionals, resulting in frustrating and inadequate encounters. Finally, despite the availability of worldwide evidence-based practice guidelines for a wide range of chronic diseases, the use of evidencebased standards remains limited. A well-established model designed to guide the reorganization of health-care delivery systems from acute and reactive care to proactive, planned and community-based care is the Chronic Care Model (CCM) developed by Wagner et al. In this systemic model, improved functional and clinical outcomes of disease management are the results of productive interactions between informed, activated patients and a prepared, proactive practice team of healthcare professionals. These productive interactions are supported by six components: health-care organization, community resources, self-management support delivery system design, decision support, and clinical information systems. To better integrate aspects of prevention and health promotion into the CCM, an enhanced version called the Expanded Chronic Care Model was developed by Barr et al. The CCM has been used widely to guide the reorganization of health-care delivery systems; however, implementation has been shown to be fragmented and limited to one or two components, mostly including self management, multidisciplinary teamwork and information systems. This defragmented and limited implementation may explain today’s poor integration of care across organizations, unbalanced skill mix and lack of patient involvement in the current health-care delivery systems. Furthermore, practices and change strategies used to reorganize health care according to CCM delivery systems vary highly across health-care systems. Several attempts have been made to adequately measure the effectiveness of reorganizing care according to the CCM. However, because of defragmented implementation, different change strategies and different measuring methods and outcome indicators, the effectiveness of reorganizing health-care delivery systems according to CCM and its impact on health-care costs remains unclear. Furthermore, it remains unclear which are the best practices that should be implemented when effectively translating evidence of CCM into clinical practice. A possible strategy to facilitate the integration of all CCM components is the implementation of a care pathway. A care pathway that bridges primary care and hospitals and allows multidisciplinary teams to interact with active patients and communities, facilitated by information technologies, can encounter defragmented implementation of the CCM and has enormous potential to optimize patient care and outcomes like hospital admissions and quality of life. The impact of care pathways on compliance to care processes and performance of outcomes is already being extensively evaluated for acute in-hospital settings. However, the focus of chronic care needs to shift towards addressing people in all stages of chronic disorders, including early stages and managing stable and long-term conditions. To develop an effective care pathway incorporating preventive, acute and long-term care, we need to know which components and, more specifically, which best practices are essential for the proper functioning and effectiveness of this care pathway. However, as addressed earlier, defragmented and diverse CCM implementation strategies and the use of diverse outcome measures means that one does not know the active essential components and practices to develop a structure like these integrated chronic care pathways. For this reason we think that some areas of research should be written on the agenda of next challenges in care pathways. First it will be necessary to identify the best practices describing ‘coordination of care across organizations and across boundaries’. This will facilitate the shift from hospital-centred systems towards integrated care systems, including managed clinical networks, multidisciplinary teams and collaborative, flexible, shared-care arrangements between primary care and hospitals and across the lines of health care, which is believed to enhance equitable access to safe, high-quality care and to reduce inequalities. Then we think it will be necessary to develop best practices on ‘knowledge translation into practice’ and ‘clinical information systems’ that will promote evidence-based policy-making and decision-making, supported by adequate health information systems. This will probably also promote the use of modern technology (such as smart phones and applications) and will improve patient access, information and disease monitoring, which is expected to lead to cost savings.