Multiple Chronic Conditions Framework Goals

HHS provides leadership in improving health outcomes for individuals with multiple chronic conditions (MCC). The Department’s vision for MCC is: optimum health and quality of life for individuals with multiple chronic conditions. One of the main steps taken towards achieving this vision was identifying four interdependent areas:

• Strengthening the health care and public health systems
• Empowering the individual to use self‐care management
• Equipping care providers with tools, information, and other interventions
• Supporting targeted research about individuals with MCC and effective interventions

Details about these four focus areas are provided in the document Multiple Chronic Conditions: A Strategic Framework (2010) [PDF - 245 KB].  

To help achieve the Department’s vision, the Framework includes the implementation of these four overarching goals:

• Goal 1: Foster health care and public health system changes to improve the health of individuals with multiple chronic conditions
• Goal 2: Maximize the use of proven self-care management and other services by individuals with multiple chronic conditions
• Goal 3: Provide better tools and information to health care, public health, and social services workers who deliver care to individuals with multiple chronic conditions
• Goal 4: Facilitate research to fill knowledge gaps about and interventions and systems to benefit individuals with multiple chronic conditions

 Goal 1: Foster health care and public health system changes to improve the health of individuals with multiple chronic conditions

Improving the health status of individuals with MCC requires increased coordination of complex medical and long-term psychosocial care. Individuals with MCC should have access to community and other public health services, as well as improved medical care coordination. Efforts to coordinate acute and long-term care systems have been difficult due to multiple providers operating independently. Unfortunately, the current model of fee‐for‐service medical care offers few financial incentives to coordinate care. Another reason traditional disease management programs have not been optimally effective is because they lack a strong link to primary care, which focuses on the treatment of individual conditions.^{1, 2}  The current situation can be improved by taking steps to achieve well‐coordinated care for those with MCC. They include changes to the delivery and provider payment system, development of accompanying quality and performance metrics, and increased involvement of the public health system.

 Goal 2: Maximize the use of proven self-care management and other services by individuals with multiple chronic conditions

Even the highest quality provision of care to individuals with MCC alone will not guarantee improved health outcomes. Along with that, individuals must be informed, motivated, and involved as partners in their own care.³ Self‐care management can be important in managing risk factors that lead to the development of additional chronic conditions. Still, some individuals with MCC (for example, those with severe illness or substantial cognitive decline) will be limited in their ability to perform self‐care. The important role that families and other caregivers provide in managing chronic conditions must be recognized and supported.

 Goal 3: Provide better tools and information to health care, public health, and social services workers who deliver care to individuals with multiple chronic conditions

Currently, there is a lack of published data regarding care for those with MCC.  It is critical to provide health care, public health, and social services professionals and family caregivers with the tools and information they need to care for individuals with MCC. Managing chronic conditions mostly occurs outside the medical care setting. It emphasizes the importance of continued care to sustain and improve adherence with prevention and treatment strategies to improve health outcomes. Attention must therefore be focused to sustain and improve adherence with prevention and treatment strategies to improve health outcomes.

 Goal 4: Facilitate research to fill knowledge gaps about and interventions and systems to benefit individuals with multiple chronic conditions

Significant gaps exist in the approach to care for individuals with MCC. Bolstering research efforts will help improve characterization of the MCC population. It will support health care and other providers in coordinating and managing care for this population. The research will assist in tracking progress to improve the health for individuals with MCC as well. This goal includes basic investigation of medical therapies and epidemiologic study of the impact of comorbidities on disease pathways. It also includes efficacy and effectiveness of promising interventions for health promotion and self‐management (as described in Goal 2), and health system care management strategies (as described in Goal 1).

References

1. Geyman JP. Disease Management: Panacea, another false hope, or something in between. Ann Fam Med 2007;5(3):257–260.
2. Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries. JAMA 2009;301(6):603–618. 
3. Greenhalgh T. Chronic illness: beyond the expert patient. BMJ 2009;338:629–631.