Managing Patient and System Complexities to Improve the Quality and Outcomes of Chronic Care

It is estimated that more than 120 million people in the United States have a chronic health condition, and 24% of those have three or more conditions.1 Overall, the veteran population is sicker and older than the general population, and a large proportion suffer from one or more chronic illnesses. For example, type 2 diabetes affects nearly 20% of veterans; ischemic heart disease is the most frequent indication for hospitalization in the VA; depression and schizophrenia account for more than 25% of VA’s total healthcare costs; and VA is the largest single provider of HIV care in the United States. Moreover, VA is now caring for a new generation of veterans who served during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Many of these veterans have suffered polytraumatic (multi-system/multi-organ) injuries, including traumatic brain injury and loss of limbs. These new veterans present our health care system with new challenges in terms of managing complex chronic care. Not only must VA provide the best care possible for veterans with multiple injuries, we also must help these young veterans learn to cope and live with chronic illness. The challenge to VA and other health care organizations is how best to serve patients with complex chronic care needs. Treating multiple chronic illnesses can be particularly difficult given that clinical guidelines are tailored to individual illnesses, and specialized care may involve multiple providers that need to work together to provide patient-centered, coordinated care. To further our understanding of the many issues surrounding chronic care, in 2006 VA’s Office of Research and Development Service (ORD) hosted a state-of-the-art (SOTA) conference on “Managing Complexity in Chronic Care.” A multidisciplinary group of more than 80 VA and non-VA policymakers, researchers, managers, and clinicians came together at this invitation-only conference to synthesize the state of the art for managing complex care from the perspective of the patients, providers, and health care system—and to identify what we know and what we need to know about this imperative health care issue. Specific conference goals included: Developing policy recommendations to assist VA and the larger health care community in their efforts to improve clinical care models and the management of patients with chronic illnesses, and Developing a research agenda that will address the current knowledge gaps in managing complex chronic care. The SOTA planning committee, chaired by Kevin Weiss, MD, MPH, Director of VA’s Center for Management of Complex Chronic Care, developed the conference agenda and commissioned papers as background providing participants with a common knowledge base to stimulate discussion. These background papers were further refined after the SOTA and are the basis of this supplement, along with several other manuscripts that were developed as a result of the SOTA deliberations. Papers address topics such as self-management in complex chronic diseases, prevalence, health consequences, and implications for quality, care management, and costs for persons with multiple chronic conditions, and information technology to support improved health care for those with chronic illnesses. I would like to thank Dr. Weiss, members of the SOTA planning committee, authors of the excellent articles included in this Supplement, and all conference participants for their expertise and dedication to identifying evidence-based strategies for managing complexity in chronic care. In addition to this Supplement, SOTA participants outlined on a research agenda that will generate knowledge to help VA provide the best possible care to thousands of veterans dealing with chronic illness. Over the last decade, VA ORD’s Health Services Research & Development Service has facilitated eight state-of-the-art conferences that have covered a range of topics vital to improving the health and health care of our veterans and the nation, i.e., leading organizational transformation, long-term care, informed consent, and implementing research evidence into practice. In the future, we plan to hold another SOTA that will focus on issues surrounding the care of OIF and OEF veterans.