Panel Discussion: Chronic Disease and Aging: Applying the Chronic Disease Model and Preventive Care among the Aged
Speakers: Dr. Wagner and Dr. Clarfield
Moderator: Renaldo Battista, MD, MPH, ScD, FRCPC, Professor, Department of Health Administration, Faculty of Medicine, Université de Montréal (DASUM).
Dr. Battista moderated a discussion focused on modifying the manner in which chronic care is delivered to the elderly, as well as the applicability of preventive care measures to a frail older patient segment. He observed that speakers Dr. Wagner and Dr. Clarfield offered differing but pragmatic approaches.
Audience members addressed continued concerns about the consequences of modifying surveillance of patients receiving chronic care. Dr. Clarfield had echoed Dr. Wagner’s and Dr. Kane’s call to replace the practice of regularly scheduled follow-ups with visits prompted by alterations in the patient’s condition or in response to flares of illness. This prompted requests for examples of how teams and systems following this model currently function.
Dr. Wagner responded that the best use of such a system involves reliance on an electronic patient registry that carefully tracks conditions and the dates of major illness-related events. For example, doctors can access the database to monitor who, among his/her patients with diabetes, has not presented for a follow-up visit in longer than 3 months. It was reiterated that such a surveillance model is meant to serve a proactive model of care of planned interactions that involves partnership between patient and physician.
Physician-patient interactions would not conclude without some discussion of follow-up, which can be electronic rather than an in-person visit. The registry facilitates the gathering and accessing of critical information, such as the date of events. A good registry enables proactive care, Dr. Wagner stated. Improved systematic follow-up triggers visits at critical health junctures, and structures key health information according to its salience.
Other questioners voiced concern about events of psychological and social impact that affect health markers. Isolation and bereavement, for example, are correlates of health decrements. Dr. Clarfield agreed that these events impact health but can be hard to medicalize or approach objectively. Here he argued for the role of public health to intervene in this domain. Dr. Clarfield suggested that the numerous supportive communities developing for the aged in Israel could serve as a model. These communities function to prevent isolation and its consequences. He cautioned against the impulse to medicalize social problems.
This prompted consideration from listeners and the panelists on whether the model of chronic disease management could potentially lose sight of the individual person.
Dr. Wagner spoke of this loss as a consequence of the structure of research and data within the chronic disease/chronic care model. Individuals with chronic disease become identified and labeled as such, leading to theoretical and practical imprecision between addressing the person with diabetes versus management of diabetes per se. This may also be a consequence of the problem’s scale, he claimed: Dr. Wagner noted that 25% of people over the age of 65 have four or more chronic conditions. Improving management of multi-morbidity is essential. This necessitates an individualized approach, which may alleviate the forces that would contribute to generalizing patients broadly according to chronic health conditions. He noted that research is beginning to study the patient with specific interrelated health markers, such as heart disease plus depression.
The speakers were asked to elaborate further on the subject, given that acute hospitals are increasingly labouring to manage individuals with multiple diseases and nonspecific deterioration. How is the case for the chronic care model approach within the hospital to be made?
Dr. Wagner stated that children’s hospitals should be consulted as models, as they better integrate the role of the multispecialty practitioner and utilize a systematic approach. These hospitals are experiencing some success at caring for children with complex environmental and genetic problems, he claimed.
He further discussed creating closer links between public health and the chronic care model, based on his and colleagues’ experiences of working with the Centers for Disease Control and state health departments. There they have been implementing the chronic care model with quality improvement initiatives. Specifically, they have observed benefits associated with public health supporting the development of multilevel care systems. Public health can play a key role in facilitating development of community-based resources for providing care such as peer support and exercise programs. Public health can also facilitate the implementation of good information technology.
Finally, the issue of medical training was brought to the speakers’ attention. The panelists concurred that if medical education merely upholds and exemplifies the traditional healthcare delivery system, trainees will understandably opt out of primary care. Dr. Wagner and Dr. Clarfield concurred that if effective systems of care can be developed, trainees will choose it.
