8 features of successful chronic illness care models

Care models that successfully achieve the Triple Aim of improved care, improved health and reduced costs in treating patients with complex needs share several common features, including targeting specific patients, evidence-based care planning and educating patients on self-care, according to an issue brief from the Commonwealth Fund.

Complex healthcare needs due to chronic conditions or functional issues are a major driver of healthcare costs, particularly among patients with socioeconomic disadvantages. The issue brief analyzed existing research to identify common attributes to effective models and programs that improved outcomes and reduced costs for these patients. 

The Commonwealth Fund cited the research conducted by Chad Boult, M.D., and Darryl Weiland, Ph.D., of Johns Hopkins Bloomberg School of Public Health, that identified four key features of effective, efficient primary care for elderly, chronically ill patients, including:

  • Detailed assessments of conditions, risks, behaviors, values and preferences
  • Patients' and family members' active involvement in care
  • Coordinated, communicative care among everyone involved in a patient's professional care with particular emphasis on hospital discharge
  • Evidence-based care strategies

It also cited a review by Thomas Bodenheimer, M.D., and Rachel Berry-Millett, M.D., at the University of California, San Francisco, which identified the following features of an effective care management program:

  • Multidisciplinary teams including physicians and specially trained care managers
  • Support of informal home caregivers
  • Education of patients and their families on self-care to head off problems or symptoms before they require hospitalization
  • Identification of complex patients whose illnesses are not so severe that palliative or hospice care would be more appropriate

The research found several programs seemed to share features but achieved different results, which the Commonwealth Fund researchers suggested could be due to variations in practical implementation. By their nature, the report added, many interventions are not universally applicable because they are developed to deal with problems within a specific community or patient population. Providers must customize interventions and best practices according to both population needs and available technology, according to the report. Similarly, the Affordable Care Act has provides incentives to providers to emphasize population health management in their strategies for chronic conditions.

Providers must also address potential barriers to implementing successful care models, including lack of monetary incentives, lack of infrastructure support, deficiencies in workplace culture and limited capacity to change models, according to the report.

To learn more:
- read the issue brief