Source: The Conversation – Canada – By George A Heckman, Schlegel Research Chair in Geriatric Medicine, Associate Professor, University of Waterloo
“The economy, stupid!” is an aphorism coined by James Carvill during Bill Clinton’s 1992 U.S. presidential campaign to keep workers focused on a key message. It has since been adapted countless times to refocus debates over challenging situations, and it can be applied to the central challenge facing health care: our ongoing failure to address the needs of people with chronic conditions. “It’s chronic disease, stupid!”
As a geriatrician with a research interest in models of care, and a cardiologist who studies rehabilitation and proactive disease management, we are immersed in this issue as both physicians and researchers.
A chronic condition is a health problem — physical, mental, developmental or age-related — that usually requires lifelong care, often causes disability, and sometimes shortens life expectancy. Symptoms may not be apparent for years, develop insidiously or arise abruptly. Chronic conditions are often unstable, and hospitalization may be required when symptoms are allowed to deteriorate significantly.
In contrast, acute conditions develop suddenly and usually resolve, such as infections, though some, such as a COVID-19 infection, may lead to chronic symptoms.
This distinction matters. Our health-care system was designed last century primarily to care for acute conditions. Back then, the population burden of chronic disease was low because treatments and survival were limited.
Advances in medical science have since resulted in better care for people with acute or chronic conditions, leading to better quality of life, delayed disability and greater life expectancy. Today, people with heart and lung disease, psychiatric and neurological conditions, and even some advanced cancers live far longer than their predecessors did only a generation ago.
Living longer comes at a cost. Age is a major risk factor for the development of chronic conditions. A person surviving a heart attack today may develop, years later, depression, heart failure and dementia. The acquisition of multiple chronic conditions is called multimorbidity.
The accumulation with age of additional deficits across all organ systems leads to frailty, and which renders affected individuals more vulnerable: a simple cold, easily withstood by a young person, can lead to pneumonia and hospitalization in a frail older person. Multimorbidity and frailty often lead to disability.
People living with complex chronic conditions are poorly served by our health-care system. Informal caregivers, aging spouses, friends or children, cannot fully compensate for health-care system gaps before they are overwhelmed by the severe and complex needs of their loved ones. The only option often remaining is best summarized by the typical message heard on physician phone lines: “If this is a medical emergency, hang up and call 9-1-1 or go to the nearest emergency department.”
The mismatch between health care designed for acute illness and the needs of patients with chronic conditions lies at the root of why hospitals are perpetually overflowing. Health care must be reconfigured to meet the needs, characteristics and health trajectories of people with chronic conditions.
Team-based primary care
People with chronic conditions need access to team-based primary care. Team composition and skills must reflect the needs of these people, and may include advanced practice nurses, clinical pharmacists, nurses, social workers, therapists or mental health workers, in addition to a primary care provider.
Highly-functioning teams have no professional hierarchies, promote interprofessional respect, communication and mutual accountability, allow all providers to exercise their full scope of practice, and place patients and caregivers first. Consultants, such as geriatricians, can be valuable team members, as shared and collaborative care provides opportunities for capacity-building, and greater quality and efficiency of care.
Having access to a team does not imply that a patient requires continuous care: the team’s role is to develop and implement a plan for patients to maintain stable and optimal health. For many, the intensity of engagement with the team will change over time.
For example, following a myocardial infarction, patients with coronary artery disease may require surgeries, risk factor modification with pharmaceuticals, diet and physical rehabilitation.
However, over time, their health will recover, they will resume more vigorous activity, and their reliance on the team will ebb to only need the expertise of their family doctor and their consultant. If new symptoms arise, the proactive and prepared team will be able to recognize these and take timely action to prevent complications and avoid hospitalization.
In other words, the degree of support needed from a team should be commensurate with, and responsive to, patient needs and the risk for adverse outcomes at a particular moment. Because the needs of patients with chronic conditions fluctuate, primary care must switch from a reactive stance to one characterized by team-based anticipatory surveillance and guidance.
Anticipating needs
Chronic conditions are predictably unpredictable. Most people hospitalized with heart failure had signs and symptoms weeks before calling 9-1-1. Suicide attempt survivors may have had mood symptoms for months. Most people with osteoporotic hip fractures had prior falls or fractures. These early warning signs should be detectable by proactive teams, which can then intervene quickly to prevent further deterioration.
Prevention remains important, even among people with chronic conditions. Astonishingly, fewer than half of Canadians who sustained a hip fracture are adequately treated for osteoporosis. Self-care coaching and case management from care teams can improve health and prevent hospitalizations of people with chronic conditions.
Self-care coaching helps patients and informal caregivers better understand how to care for chronic conditions, including recognizing early signs of deterioration, taking steps to stabilize their health and, if needed, seeking timely attention from their care team. As patients and caregivers master these skills, health improves, the risk of hospitalization and other poor outcomes decreases, and their reliance on their care team lessens.
Case management provides additional and tailored support and oversight to patients with the most complex needs.
Both modalities can be deployed interchangeably to support a patient and informal caregiver as their health fluctuates, including at the end of life. Yet, despite their demonstrated effectiveness, these availability of these interventions for complex conditions remains limited in primary care.
Integrating the health system into primary care
Even the most high-performing teams require external support from other consultants or programs, rehabilitation and exercise, home care, community paramedicine or other community support services. Typically, family physicians complete referral forms for these services, and accepted patients are placed on waiting lists. Communication between primary care and other providers is generally by fax or by letter, often with limited information and little opportunity for discussion.
Health system integration is a system-wide process towards seamless continuity of care through collaboration and co-ordination of providers. Evidence suggests that integrated care improves patient outcomes and reduces reliance on acute care.
In addition to interprofessional teams, integration requires an electronic standardized clinical information strategy to facilitate effective communication between providers and facilitate shared learning and quality improvement. Importantly, public investments are required to support the shared governance, administrative and scientifically robust electronic health record infrastructures for successful integration.
It’s still the economy, stupid!
A well-integrated interprofessional health-care system, rooted in primary care and configured to support patients with chronic conditions and their informal caregivers, has the potential to improve health outcomes, curb health-care spending and reduce reliance on hospital care.
However, this measure alone is insufficient to curb the population burden of chronic conditions, for which important root causes are socioeconomic: childhood poverty and undernutrition, low educational attainment and experience, food insecurity and precarious housing.
Population health and a healthy economy are inextricably linked. Government policies that fail to meaningfully support public health and social safety nets ultimately drive higher chronic disease rates and greater downstream health-care costs.
When it comes to health care and chronic conditions, Carvill’s aphorism still applies.
The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
– ref. ‘It’s chronic disease, stupid!’ The central challenge facing health care – https://theconversation.com/its-chronic-disease-stupid-the-central-challenge-facing-health-care-275770