The National Board of Health relatively early took leadership in developing a chronic care model – in part in view of the demographic development discussed above, in part because the prevalence of chronic illnesses
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was increasing independently of the demographic development due to life style changes. In a number of reports a ‗chronic care‘ model described below was developed103-110. It is a definite strength that the chronic care model is being promoted vigorously by the National Board of Health, including establishment of a steering group for chronic care with representatives from municipalities, regions, and government, but unfortunately not with a GP representative. A dynamic project on chronic care has also been established by the National Board of Health. A weakness is that the uptake of the model seems rather slow and much depends on the (good) will of the parties involved in the operational details: Municipalities, GPs and the Regions. GPs are formally a regionally financed entity, but run by self-employed GPs on contract with the region. There has been much talk and understanding but not a corresponding level of coordinated action whereas many examples of independent municipal and regional projects are seen. Central government has approved 0.6 billion DKr. that has been allocated to projects that run 2010-2012. However, one may question the number of project. Looking at the list of projects110 it is clear that an attempt has been made to consider
‗everybody‘ – probably resulting in too many and too small projects with no guarantee that good project results will become part of the annual budget once project money run out.
It is also a strength (and a weakness) that chronic care is an integral part of the compulsory health agreements111 between regions/GPs and the municipalities, but it has been hard to obtain commitment to concerted action.
The National Board of Health describes the background for the initiative as follows:
―Due to the emergence of increasingly efficient and costly treatment options, an ageing population and the ensuing increase in the number of people affected by chronic diseases and problems recognized in the care of chronic conditions it is necessary to identify the options for better care in connection with chronic conditions, p.4107
Chronic diseases can be defined by one or more of the following characteristics: they are permanent, leave residual disability, are caused by non-reversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation or care. This definition includes both somatic and mental disorders.
The list of specific chronic diseases usually encompasses:
diabetes
asthma and allergy cancer
chronic obstructive pulmonary disease (COPD /KOL) cardiovascular disease
osteoporosis
muscular-skeletal diseases, typical rheumatism psychiatric diseases
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The chronic care model was basically developed in the US112. The basic ideas and issues are captured in figure 23. Starting from the left we have what is formally the ‗chronic care‘ model. An essential element is the collaboration between the health system and the community (in Denmark among other things the municipalities and NGOs). Another important element is self care. The National Board of Health has been strong in stressing this element103, 109, 113
.106. An important element of self care is monitoring – where telemedicine may become an important tool. The National Board of Health states that: ―The patients' self-monitoring of the disease should be enhanced and technologies for self-self-monitoring should be evaluated and the quality of the monitoring should be assured‖, p. 7110.
The stratification model in the middle of Figure 23 stresses both the division of work and the importance of primary care. It is of course an idealized model but on the other hand it also shows how important it is to discuss and implement ways of ensuring that patients as much as possible are treated at the local level. The work with patient pathways for chronic patients is an important way to realize this108. .
To the right in the figure is collaboration triangle in Danish health care. The chronic care model is a generic model –albeit implicit mirroring an American setting. The model needs to fit a Danish setting and in particular to capture the three main parties. Much is done formally through the health agreements, but more importantly is the day to day collaboration. One particular challenge is to decide on who is to lead. The recommendation is clear: ―…the general practitioner is the project leader through the entire course of the chronic disease and that the contents of the function are incorporated into the description of the course.‖.
The question is whether this is accepted by the other parties and whether general practice and will take on this task.
Figure 23: A snapshot of the chronic care model
In view of the previous recommendation it should be noted that general practice already is heavily involved with chronic patient, figure 24. Almost 50% of face-to-face encounters are with chronic patients.
60 Figure 24: Chronic diseases and general practice114
The totality of the chronic care has not been subjected to rigorous evaluation, only parts, e.g. the self-care component, (Lorig 1999). Hence, one must be careful not to make too sweeping generalizations or claims.
The chronic care model can be looked at from several perspectives:
as a way of providing care in the primary care sector and avoiding ‗clogging‘ in-and outpatient care.
In this respect the model is worth looking at – in particular if outcomes are equal or better than for hospital care
producing better outcomes. A recent summary of studies seem to provide some support for this, (Coleman 2009)
does it create net savings or at least provide cost-effective care compared to for instance mainly hospital care. One should probably not expect net-savings. (Peikes 2006; Peikes 2009; Russel 2009).
At best it is cost neutral.