SOC313 Introduction to the Miller Family Sarah (40 y.docx

SOC313
Introduction to the Miller Family
Sarah (40 yrs) and Joe Miller (43 yrs) are at the center of this
family. [See the geneology maps (family
trees) for both Sarah and Joe below.] They are a middle aged
couple, married 21 years with three
children. Their children are Lucy (20 yrs), Josh (17 yrs), and
Abe (12 yrs). Lucy has had struggles with
substance abuse, along with having been diagnosed with bipolar
disorder. Josh has been sneaking away
with friends and smoking pot. Abe is a good student but has
started to act out recently.
Sarah’s parents are Donna and Manny Maldonado. Manny is
third generation Hispanic American from
Mexico. Donna has long suffered from her “moods” which is
mostly frustrating to Manny. He says it’s
“brujeria” (related to witches and magic). He worries that
someone puts spells on her. They both are
fluent in Spanish, Donna having learned as a result of being
with Manny and around his family. Sarah is

their oldest daughter followed by her brother, Mike (36) and
then sister Becky (33). Becky, divorced,
has one child, Elías (10 yrs old) who was recently diagnosed
with Leukemia. Mike is alone, having
recently suffered the loss of his companion of many years to
AIDS. He is secretly also concerned that he
might be HIV+.
Joe’s parents are Ella and John Miller. Ella is at the center of
our story as she has been trying to heal
herself from breast cancer through the use of a variety of
natural means. She was raised on a farm and
is not very trusting of “modern medicine.” Her husband, (Joe’s
father) John is of American Indian origin.
He uses a variety of traditional methods for health and well
being and as a means of banishing bad
spirits from their home. Ella’s mother passed away over ten
years ago but her father is still alive. He is
often referred to as the “shakey grandpa” by the grandchildren
and great grandchildren due to the
manifestation of some symptoms of his Parkinson’s disease.
Joe has a sister, Lila (45 yrs), who has diabetes and who has
always struggled with her weight. She and
her husband have one child, Alisha (20), who’s currently in
college. Joe’s older brother Sam (50 yrs), was

married and then divorced years ago, has one son from whom he
is estranged. He is an alcoholic who
hasn’t been able to keep a job for years.
The family and extended family get along well for the most part
though the many cultural traditions and
backgrounds do clash from time to time. Manny, for example,
has been known to say, “They’re crazy!”
when the family discusses some of the health issues that are
going on and how they are being handled.
At one time, for example, Ella’s skin turned orange due to the
amount of carrot and other juices she was
consuming in order to get rid of her cancer.
Sarah has been married to Joe long enough to know her well and
when her sister Becky’s son Elias was
recently diagnosed with Leukemia, Ella was hopeful that Sarah
would encourage Becky to use natural
means for treating him. Sarah isn’t really too sure about how
she feels about it.
Sara Miller’s family tree
Joe Miller’s family tree

STEPS FOR EFFECTIVE DISCHARGE PLANNING
New York State requires hospitals to provide discharge-
planning services to facilitate
your transition from hospital to home (or another setting such as
short term rehabilitation
or skilled nursing facilities).
Discharge planning provides a critical link between the
treatments received when a
patient is hospitalized, in rehab or at a skilled nursing facility.
Ideally one designated
person or team is accountable for effective discharge of
patients. This maybe the
patient’s primary nurse, a case manager, a dedicated discharge
planner or an inter-
disciplinary team. (i.e. physicians, social workers)
Discharge planning is not a single intervention as many issues
need to be addressed
including safety. There is information available for the
caregivers of the patients being
discharged however there is little information for the patients
who live alone.
Medicare defines discharge planning this way:
A process used to define and to decide what a patient needs for
a smooth move from one
level of care to another.
Discharge is a short-term plan to get you out of the hospital or

institution not a blueprint
for the future. At the very outset of discharge planning, health
care professionals, family
caregivers, and the patient (if appropriate) should discuss the
following:
• The patient’s condition, and any changes that may have
occurred as a result of
treatment as the facility;
• Any likely symptoms, problems, or changes that may occur
when the patient is at
home;
• The patient’s care plan, the caregiver’s needs, and any
adjustments that must be
made to meet these needs;
• The potential impact of caregiving on the caregiver; warning
signs of stress;
techniques for reducing stress.
Planning
Prior to discharge, health care professionals should work with
family caregivers - with
the patient’s consent, if appropriate to:
• Arrange for an assessment to determine Medicare or insurance
eligibility for
home care services, such as visiting nurses and home care aides;
• Set up home care services for which the patient is eligible and
others for which
the patient / family will pay;

• Get the home ready by arranging for equipment rental and
home modifications;
• Schedule a follow up appointment.
1
Training
Before discharge, healthcare professional should provide family
caregivers with
applicable training, including:
• A written medication list with specific instruction on
medication dosages and
how long they should be taken and information about possible
side effects;
• Teaching and practice of techniques such as bed to chair
transfers, care
procedures, use and monitoring of equipment, recognition of
symptoms, and other
element of patient care.
• Equipment: Who (company)?
What items?
When delivery? Phone _______________
Referrals
Before discharge, healthcare professionals, caregivers, and
patients should explore

available support services, including:
1. Community sources of social support for caregivers and
patients;
2. Community-based agencies that provide services such as
transportation,
equipment maintenance, respite care, home care, and volunteer
services;
3. Information resources such as books, pamphlets, videos, and
websites.
You may have other concerns and questions as well. Write
them down as you think of
them. Again, remember the first “Be realistic. Make sure you
have someone else with
you or to call on until you feel comfortable with the new
situation. And don’t be afraid
to talk – to the doctor, the home care agency, and your family –
if you feel unsure.
In most cases it takes a while to settle in, so don’t expect
everything to be the same as
before. But help will not be available unless you ask for it. Be
persistent.
In hospitals or institutions many patients require post-discharge
care, conveying
information about specific needs to each patient who may
benefit from different services
will take a lot of ingenuity.
Patient Safety Program
In the environment we are now working in (with regard to safe
discharge to home)

certain issues need to be addressed.
1. Does the patient live alone? If the patient lives alone will the
patient be
able to manage medications, shopping, doctors appointments,
general
housekeeping, bathing and all other safety issues: (i.e. clutter –
throw rugs
– shower rails – stairs – toileting.
2. Is home care appropriate for the patient?
3. Does insurance cover services?
4. Can the patient pay privately?
2
THINGS TO KNOW WHEN YOU ARE IN THE HOSPITAL
New York State requires hospitals to provide discharge planning
services to facilitate
your transition from hospital to home (or another setting such as
short term rehabilitation
or skilled nursing facilities).
Your initial hospital stay may be a time of concern, such as --
unknown procedures,
terminology etc. but ask who your discharge planner will be so
you can be appropriately
prepared. Please let the discharge planner know if you have any
special concerns, needs,

and issues regarding returning home.
The discharge planner will be a nurse and/or social worker, who
is available to assist you
with post hospital plans for necessary services which can
include: visiting nurse,
custodial care by a home health aide, therapy, medical
equipment to name a few. You
should receive this information in writing. The discharge
planner will also help to
determine your insurance eligibility for necessary services.
As a Medicare recipient if you think you are being asked to
leave the hospital too soon
when the hospital gives you a written notice of discharge -- you
may question your
hospital discharge. The notice will say “Who you should call
and how to appeal”.
Being prepared during your hospital stay will help to avoid any
last minute
problems.
3
Juice Images/SuperStock
Learning Objectives
1. Identify the differences between disease management and
integrated care programs
2. Discuss the types and prevalence of chronic illness and

disability (CID) and its potential impact on
economic growth
3. Compare and contrast the different models used to understand
CID
4. Discuss the various incentives to improve CID care and
reduce costs
5. Compare different care systems for patients with CID in
Europe and the United States
6. Discuss new research programs aimed at understanding and
reducing the impact of CID
International Approaches
to Dealing With Chronic
Illness and Disability
11
Zjsight/Imaginechina/Associated Press
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CHAPTER 11Section 11.1 Introduction to International
Approaches to Chronic Illness and Disability
11.1 Introduction to International Approaches to Chronic
Illness and Disability
The United States has experienced four decades of growth in
chronic illness and disability (CID), which now accounts for a
majority of health-related diseases and deaths. Although the
United States was the first to reach this milestone, other
developed and many devel-
oping countries are catching up. According to the World Health
Organization (WHO), 63% of
deaths in 2008 were attributable to noncommunicable diseases
(NCDs), principally cardiovascu-
lar disease, diabetes, cancer, and chronic respiratory ailments
(WHO, 2011c). However, in con-
trast to popular belief, only 20% of these deaths occured in
high-income countries, whereas 80%
occured in low- and middle-income countries, where the
majority of world’s population resides
(WHO, 2005).
The management of CID is one of the most important challenges
the world faces. As the global
population ages, the prevalence of CID is expected to increase
significantly, particularly in lower
income countries. The social and economic implications of this
epidemic are profound. Some see
it as the most significant (though predictable) potential crisis
that governments will confront.
Currently, the management of CID accounts for 2% to 15% of
national health expenditures in
some European countries. Indeed, millions of people are pushed
below the poverty line each year

because of higher out-of-pocket expenses for medications and
health care services.
How CID is managed varies from country to country and within
countries. Approaches include
care coordination led by a general practitioner (GP),
multidisciplinary teams, managed discharge,
nurse-led care, and case management. Newer approaches such as
disease management programs
(DMPs) and integrated care programs are also receiving
attention. This chapter discusses these
approaches in more detail. In addition, some countries are
experimenting with registries, while
others are integrating surveillance for selected risk factors
(blood glucose level, blood pressure,
cholesterol, alcohol and tobacco use, poor diet, overweight and
obesity, and physical inactivity)
into their national health care information databases.
Governments, civil society, and the private sector are forging
partnerships and collaborations in
order to implement key activities related to CID. Also, funds to
influence risky behaviors related
to CID are being developed, and payers, providers, and patients
are being offered incentives for
compliance and improved outcomes. Almost all these new
strategies have as their key component
involving the patient in developing treatment plans and goals,
prevention, and targeted interven-
tions based on standardized guidelines. The strategies aim to
enhance functional status, improve
quality of life, and prolong life. However, among countries,
these endpoints are approached
differently.
Building on the context of what the student has already learned

about how chronic illness is
viewed, experienced, and treated in the United States, this
chapter discusses these subjects from
an international point of view. The content is intended to help
the student view the problem of
chronic disease in a broader, more global context, as it truly is a
world problem, not just a U.S.
problem, and certainly will loom larger in the future.
H1_intro
TX_DC
BX1_H1
BX_TX
Running head
KT
bold ital
atL80953_11_c11.indd 346 12/5/13 1:46 PM
CHAPTER 11Section 11.2 How Big a Problem Is CID?
11.2 How Big a Problem Is CID?
Chronic diseases cause more deaths than any other type of
disease. CID is expected to increase as the worldwide
population grows and its average age increases. Throughout the
world, society makes elevated blood pressure, high cholesterol,
and obesity equally “avail-

able” (that is, the environmental conditions are contributing to
its development). Thus, diseases
previously associated mostly with wealthy populations
(cardiovascular disease, cancer, chronic
respiratory disease, and diabetes) are fast becoming diseases of
the poor. Of the projected 64
million deaths worldwide in 2015, 41 million (64%) are
expected to result from chronic disease
(WHO, 2005). The economic impact of CID—particularly in
developing countries—will be substan-
tial if not adequately addressed.
Global Growth Comparison With the United States
As of August 19, 2013, the U.S. population stood at 316.5
million, and the world population, at
7.1 billion (U.S. Census Bureau, 2013). In the United States,
about 14% of this 316.5 million are 65
years old and older, and the number of seniors is growing
rapidly. Chronic disease touches the lives
of just about every American in one way or another.
Approximately 47% (133 million) of the U.S.
population suffers from some form of chronic disease (CDC,
2005); that percentage is expected to
increase to 49% by 2030 (see Figure 11.1). The Centers for
Disease Control and Prevention (CDC,
2006b) reported that about one fourth of individuals with
chronic conditions report limitations in
one or more daily activities, a cohort size that is also
increasing.
Figure 11.1: Percentage of the U.S. population with chronic
conditions, 1995–2030
Just about every American is affected by chronic diseases,
either directly or indirectly, and approximately
47% suffer from a chronic condition.

Source: Wu, S-Y., & Green, A. (2000, October). Projection of
chronic illness prevalence and cost inflation. RAND
Corporation.
42
* Values projected from this baseline years
44 46
Percent
Y
e
a
r
48 50
2030
2025
2020
2015
2010
2005
2000
1995*
atL80953_11_c11.indd 347 12/5/13 1:46 PM

The cost of chronic disease to the U.S. economy is currently
estimated at $1.3 trillion annually and
is expected to balloon to $4.2 trillion by 2023 (DeVol &
Bedroussian, 2007).
Compared with their European counterparts, twice as many
older adults in the United States
have heart disease and arthritis. The U.S. population also has
higher rates of cancer (12.2% com-
pared with 5.4% of Europeans) and
diabetes (16% versus 11% of older
Europeans). The most common
reasons given for these differences
are tobacco use and obesity, both
of which are more prevalent in the
United States. About one third of
older U.S. adults are classified as
obese versus 17.1% of older Euro-
peans, and 53% are active or for-
mer smokers compared with 43% of
European adults (Thorpe, Howard,
& Galactionova, 2007).
In the United States, 72.5 million
adults and 12.5 million children and
adolescents are obese (CDC, 2010a,
2011e). Obesity is a growing con-
cern worldwide, particularly the
rapid increase reported in low- and
middle-income countries as they transition to western diets high
in processed food, fats, salt, and

sugar. Obesity is also associated with higher medical costs, a
lower quality of life, and an increased
disease burden and mortality rate (see Figure 11.2).
Digital Vision/Thinkstock
Consuming processed food promotes obesity that leads to
cardiovascular and glucose-processing diseases.
atL80953_11_c11.indd 348 12/5/13 1:46 PM
Figure 11.2: Percentage of deaths attributable to raised body
mass index by
country, all ages, 2002
Obesity is a growing concern worldwide.
Source: Beaglehole, R., & Epping-Jordan, J. (Eds.) (2005).
Preventing chronic diseases: A vital investment, 53. Geneva,
Switzerland: World Health
Organization, p. 53. Retrieved from
http://www.who.int/chp/chronic_disease_report/full_report.pdf.
Copyright . World Health Organization (WHO).
Used by permission.
The cost of chronic disease is enormous, accounting for 75% of
U.S. health care spending (CDC,
2013d) and is predicted to grow as the nation’s average age
increases. These persistent conditions
favorable to CID lead to death, lifelong disability, compromised
quality of life, lost economic oppor-
tunity, and burgeoning health care costs. Public and private

total health care spending amounted
to a staggering $1.5 trillion in 2005 (CDC, 2005) and is
expected to reach $6 trillion by midcentury
(DeVol & Bedroussian, 2007).
Within the U.S. health care system, Medicare beneficiaries
experienced a high prevalence
of chronic disease, according to a 2010 study. The most
common diseases were hypertension
(58%), high cholesterol (45%), heart disease (31%), arthritis
(29%), and diabetes (28%). Of greater
concern, more than two thirds of these individuals had at least
two or more chronic conditions
(Centers for Medicare & Medicaid Services [CMS], 2012). They
also represented a dispropor-
tionate share of Medicare spending. In 2010, the average annual
spending for Medicare fee-for-
service (FFS) beneficiaries was $2,025 for those with one
chronic condition or none (32% of bene-
ficiaries), $5,698 for those with two to three conditions (32%),
$12,174 for those with four or five
conditions (23%), and $32,658 for the remaining 14% with six
or more chronic conditions (CMS,
2012). This last group also accounted for 70% of all Medicare
hospital readmissions (CMS, 2012).
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atL80953_11_c11.indd 349 12/5/13 1:46 PM
http://www.who.int/chp/chronic_disease_report/full_report.pdf
Progress toward controlling these chronic diseases has been
made but has not been consistent.
For example, the American Recovery and Reinvestment Act of
2009 allotted $650 million for
reducing the risk factors for, and promoting measures to
prevent, chronic disease by encouraging
higher levels of physical activity, improving nutrition, lowering
the prevalence of overweight and
obesity, and decreasing tobacco use and exposure to secondhand
smoke (U.S. Department of
Health and Human Services, 2013d).
Also, although the United States has seen a 60% decline in age-
adjusted death rates from cardio-
vascular disease as a result of reduced tobacco use, improved
blood pressure, cholesterol control,
and new and more effective treatments (Halpin, Morales-
Suarez-Varela, & Martin-Moreno, 2010),
the prevalence of heart disease is increasing in developing
countries (e.g., southeast Asia and the
eastern Mediterranean). The CDC estimated that 80% of heart
disease, stroke, and type 2 diabe-
tes, and that 40% of cancer could be prevented by eliminating
just three risk factors: poor diet,
inactivity, and smoking (CDC, 2009). Note that some of the

differences in CID prevalence among
countries reflect their uneven screening practices.
Global Epidemic of Chronic Disease
As underscored, CID accounts for the majority of deaths
globally. A report from a 2011 United
Nations (U.N.) meeting (in which 113 member states
participated) noted 300 million CID-
related deaths in the last decade, with low- and middle-income
countries seeing the fastest
growth (Alwan, 2010). And approximately 70% of individuals
who die from CID in low- and
middle-income countries die before the age of 70. Almost 30%
of these deaths are of individu-
als younger than 60 years, compared with only 13% in high-
income countries. The loss of such
a large proportion of the working population reduces
productivity, increases health care costs,
and puts a significant burden on national economic
development. It also traps millions of peo-
ple who often pay for health care out of pocket in chronic
poverty. In Mexico, for example, it
is estimated that to treat all the patients with obesity-related
diseases would cost US$500 per
case annually—more than Mexico’s total health care budget
(Alwan, 2010).
Regions of the world where NCDs account for the majority of
deaths include the Americas, the
eastern Mediterranean, the European region, southeast Asia, and
the western Pacific. To illus-
trate the magnitude of this problem, note this comparison:
Deaths from CID are estimated to be
13 times higher than deaths due to communicable, maternal,
perinatal, and nutritional causes
combined. Only in low-income countries do the nutritional

causes result in more deaths.
atL80953_11_c11.indd 350 12/5/13 1:46 PM
Figure 11.3: Total deaths by cause, World Health Organization
region, World
Bank income, and sex, 2008
Conditions identified in the figure are more likely to result in
death for men and women who live in lower-
middle–income countries.
Source: Alwan, A. (2010). Global status report on
noncommunicable diseases. Geneva, Switzerland: World Health
Organization (p. 10). Retrieved from
http://www.who.int/nmh/publications/ncd_report_full_en.pdf.
Copyright . World Health Organization (WHO). Used by
permission
Significant increase in the prevalence of CID is expected to
occur in low- and middle-income coun-
tries as a result of increased longevity, population growth, and
greater commercial globalization,
resulting in changes in behavioral, occupational, and
environmental risk factors. Worldwide, CID
deaths are projected to increase by 15% between 2010 and 2020,
with the greatest increases
occurring in Africa (where currently more people die from
infectious diseases than from CID),
southeast Asia, and the eastern Mediterranean. No increase is
forecast for the European region
(Alwan, 2010). The largest increases in CID-related mortality

will occur in Africa and countries with
similar national gross national products (Alwan, 2010). By
2030, CID in low- and middle-income
countries will result in 3 times as many disability-adjusted life
years and nearly 5 times as many
deaths than any other cause (WHO, 2008).
AFR AMR EMR EUR SEAR WPR Low-
income
Lower-
middle
class
Upper-
middle
class
High-
income
AFR AMR EMR EUR SEAR WPR Low-
income
Lower-
middle
class
Upper-
middle
class
High-
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Males Females
Injuries
Note: AFR = African Region, AMR = Region of the Americas,
EMR = Eastern Mediterranean Region, EUR = European
Region, SEAR = South-East Asia Region, WPR = Western
Pacific Region.
Noncommunicable diseases
Communicable, maternal, perinatal and nutritional conditions
atL80953_11_c11.indd 351 12/5/13 1:46 PM
http://www.who.int/nmh/publications/ncd_report_full_en.pdf
Prevalence and Risk Factors for CID in Geographic Regions
In 2008, the leading causes of CID for individuals younger than
age of 70 were cardiovascular
diseases, cancers, respiratory disease (including asthma and
chronic obstructive pulmonary dis-
ease [COPD]), digestive diseases, diabetes, and other NCDs
(Alwan, 2010). Cardiovascular disease

(heart disease and stroke), cancer, respiratory diseases, and
diabetes account for 86% of all deaths
in Europe and a substantial amount of disability.
Figure 11.4: Proportion of global noncommunicable deaths in
people younger
than age 70 by cause, 2008
Cardiovascular diseases are the leading cause of deaths for
individuals under the age of 70.
Source: Alwan, A. (2010). Global status report on
noncommunicable diseases (p. 10). Geneva, Switzerland: World
Health Organization, 11. Retrieved from
http://www.who.int/nmh/publications/ncd_report_full_en.pdf.
permission
Country income has a significant impact on regional variations
in the frequency and types of
cancers. Within upper-middle–income and high-income
countries, prostate, breast, lung, and
colorectal (decreasing frequency) are the most commonly
diagnosed cancers in males and
females. In low- and middle-income countries, by contrast, the
most common types are lung,
stomach, and liver cancer in males; and breast, cervix, and lung
cancer in females. With the
exception of cervical and liver cancers, rates for all cancers
rose in proportion to increased
country income. Thus, in the future, the greatest growth in
cancer incidence is expected in the
low- and middle-income countries.
Globally, 10% of individuals 25 years old and older had been
diagnosed with diabetes in 2008.

Of the six WHO geographical regions considered, the
prevalence of diabetes was highest in the
eastern Mediterranean region and the region of the Americas.
European and western Pacific
regions had the lowest prevalence. The prevalence was lower in
low-income countries (8%) than
in upper-middle–income countries (10%; Alwan, 2010).
Cancers
27%30%
4%
39%
Cardiovascular disease
Diabetes
Chronic respiratory diseases
Digestive diseases
Other noncommunicable diseases
atL80953_11_c11.indd 352 12/5/13 1:46 PM
http://www.who.int/nmh/publications/ncd_report_full_en.pdf
Four modifiable behaviors (tobacco use, physical inactivity,
unhealthy diet, and harmful use of
alcohol) have been strongly associated with and causally linked
to the majority of CIDs. These
behaviors have a relationship to several metabolic or

physiological changes: hypertension, over-
weight and obesity, increased blood glucose levels
(hyperglycemia), and increased cholesterol
levels (hyperlipidemia). Among these changes, hypertension has
been associated with the most
deaths (13%), followed by tobacco use (9%), physical inactivity
(6%), hyperglycemia (6%), and
overweight and obesity (5%; WHO, 2011a).
To give an example of the connection with these risk factors,
80% of coronary heart disease and
cerebrovascular disease result from tobacco use, physical
inactivity, and unhealthy diet (WHO, 2009,
2011a). These risk factors are present to varying degrees in
various regions and based on income
levels within regions. And, overall, tobacco use is higher among
men than among women world-
wide. However, striking intercountry sex differences emerge
that appear to be related to social and
economic factors: Both higher income and increased female
empowerment are associated with
more similar smoking patterns among women and men
(Hitchman & Fong, 2011). Globally, more
than 31% of adults aged 15 years and older were insufficiently
active in 2008, and the highest inac-
tivity scores were tallied for the Americas and the eastern
Mediterranean, and the lowest were in
southeast Asia. When the data are assessed by income, a greater
percentage of the population in
high-income countries is inactive compared with low-income
countries. High levels of inactivity are
also seen in some middle-income countries, especially among
women (WHO, 2011a).
It is increasingly accepted that a diet of processed foods high in
fats and sugars promotes obesity

that leads to cardiovascular and glucose-processing diseases.
More high-fat foods are consumed
in the Americas and Europe than in Africa and southeast Asia.
The availability of saturated fats
is around 8% in low- and lower-to-middle–income countries,
but 10% in upper-middle–income
and high-income countries (WHO, 2011a). Per capita alcohol
consumption in the European region
(12.2 liters) is a dramatic 24 times higher than in the eastern
Mediterranean (0.6 liters). Alcohol
consumption in upper-middle– and high-income countries (~10
liters) is more than double that of
low- and lower-middle–income countries (~ 3 to 4 liters; WHO,
2011a).
The direct results of these high-risk behaviors are increased
mortality and morbidity associated
with hypertension, overweight and obesity, hyperglycemia, and
hyperlipidemia. In 2008, about
40% of adults aged 25 years and older were reported to have
hypertension. The highest reported
prevalence was in Africa (46%), and the lowest, in the Americas
(35%). High blood pressure is a
risk factor for stroke and coronary heart disease. Being
overweight or obese can lead to hyperten-
sion, cholesterol imbalance, and insulin resistance. The risk of
developing coronary heart disease,
ischemic stroke, and type 2 diabetes increases steadily with
increasing body mass index. Being
overweight appears to be more of a problem for upper-middle–
and high-income countries (the
Americas, Europe, and the eastern Mediterranean) than for the
low- and lower-middle–income
regions (African, southeast Asia, and the western Pacific)
(WHO, 2011a).

The problem does not appear only in adults. The number of
children with weight problems has
increased globally since 1990 and is rising the fastest in lower-
and middle-income countries. In
2008, 40 million (6%) of preschool children had a weight-for-
height ratio more than two standard
deviations above the WHO child growth median.
High total cholesterol is another major risk factor for ischemic
heart disease and stroke in both
high- and low-income countries. The European region (54%)
had the highest prevalence of ele-
vated total cholesterol, followed by the Americas (48%), the
eastern Mediterranean (39%), the
western Pacific (38%), southeast Asia (30%), and Africa (23%;
Alwan, 2010).
atL80953_11_c11.indd 353 12/5/13 1:46 PM
CHAPTER 11Section 11.3 Definitions of CID
Web Field Trip
Did you know that NCDs—such as heart disease, stroke, cancer,
asthma, and diabetes—are the world’s
biggest killer? These diseases develop as a consequence of a
person’s lifestyle and living environment.
Young people are hit hard by NCDs, because lifestyle habits are
often adopted at this stage of life and
frequently remain well into adulthood. Watch the video “Non-
Communicable Diseases: The Common-
wealth Shines a Light”
(http://www.youtube.com/watch?v=OOyYip7Lsl8).
Critical Thinking Questions

1. What is the advantage of targeting these problems early in
life?
2. How do you see the social and physical environment
influencing various unhealthy
behaviors in the countries featured?
Although the number of CID-related deaths is expected to
increase significantly in the coming
decades, North America, Latin America, and Europe are making
progress toward reducing smok-
ing prevalence and blood pressure. Efforts are also being made
to reduce people’s salt and fat
intake and the harmful use of alcohol, and to increase time
spent in physical activity. The invest-
ment is bound to pay off for these countries: Just three
behavioral modifications—eating a healthy
diet, increasing physical activity, and maintaining a healthy
body weight—can reduce a person’s
risk of type 2 diabetes by 50%.
11.3 Definitions of CID
There are a number of ways to define CID. The U.S. National
Center for Health Statistics defines a disease as chronic if it
lasts more than three months, cannot be prevented by vaccines
or cured by medication, and rarely disappears (“Definition of
Chronic Disease,”
2012). In Australia, a CID is described as an illness that is
prolonged in duration, does not often
resolve spontaneously, and is rarely completely cured
(Australian Government Department of
Health and Aging, 2012). A CID is also sometimes labeled as an
NCD, defined as a lasting medical
condition that is usually noninfectious (except for HIV/AIDS)

in origin. The WHO defines chronic
disease as having a duration of more than three months and
generally slow progression (WHO,
2013a). See Chapter 2 for a fuller discussion of various models
for understanding chronic illness
and disability.
Approval of the International Classification of Functioning,
Disability, and Health (ICF) by the
World Health Assembly in 2001 led to the development of a
universally accepted conceptual
model for classifying disability by body functions and structure,
domains of activity, and partici-
pation and environment factors. The ICF standard is used to
measure health and disability at the
individual, institutional, and societal level (WHO, 2013c). It
makes health information from multi-
ple settings, across various applications, and across countries
comparable, and enables social pol-
icy makers to devise interventions, strategies, and policies
regarding prevention and treatment.
(See Chapter 2 for more details about the WHO’s ICF model
and for a discussion of contemporary
issues in its implementation.)
atL80953_11_c11.indd 354 12/5/13 1:46 PM
http://www.youtube.com/watch?v=OOyYip7Lsl8
Societal Attitudes Toward Disability
In the first half of the 20th century, persons with disabilities
were often viewed as unhealthy,
defective, or deviant. During the last half of the 20th century,

attitudes regarding people with
disabilities changed significantly, especially in the United
States.
United States
Many legislative and societal changes that occurred in the 1960s
and 1970s in the United States,
such as the Mental Retardation Facilities and Community
Mental Health Centers Construction
Act of 1963, the 1964 Civil Rights Act, and Section 504 of the
Rehabilitation Act of 1973, prohib-
ited discrimination against otherwise qualified handicapped
persons in any federally supported
program. The 1990 Americans with Disabilities Act (ADA)
broadened those protections by guar-
anteeing all persons with disabilities a chance at full inclusion
into the mainstream of American
life. The ADA, in turn, has had a direct influence on attitudes
toward people with disabilities (Uni-
versity of Florida, 2013).
Europe
In Europe, a growing tendency to see disability as a human
rights issue (Quinn & Degener, 2002)
and self-organization by people with disabilities (Campbell &
Oliver, 1996) have also changed
attitudes. One 2001 European study reported that eight out of 10
Europeans felt at ease in the
presence of people with disabilities (European Opinion
Research Group [EORG], 2001). Countries
where people were most at ease included Denmark, the United
Kingdom, Sweden, the Nether-
lands, Spain, and Ireland. Germany and Greece were at the
lower end of the scoring. The 2005
Disability Discrimination Act passed by the U.K. Parliament
directed public-sector organizations

to promote equality for persons with disability (Prime
Minister’s Strategy Unit, 2005).
Still, more than 40% of Europeans feel other people are uneasy
in the presence of individuals with
disabilities and unanimously agree that more effort and money
should be applied to integrate
people with disabilities into society. Interestingly, the public
believes this is not a personal respon-
sibility, but the responsibility of central and local public
authorities (EORG, 2001). Respondents
to a 2009 British survey expressed the belief that benevolent
prejudice against the disabled was
widespread; however, they did not consider themselves
prejudiced (Staniland, 2009).
Table 11.1: Perceived prejudice against disabled people in the
United Kingdom, 1998–2009
A Lot (%) A Little
(%)
Hardly
Any (%)
None (%) Don’t
Know (%)
Sample
Size
1998 25 51 15 6 2 3,139
2000 35 51 9 3 6 3,422
2005 25 50 17 8 1 3,193

2009 26 53 15 5 1 2,282
Source: Staniland, L. (2009). Public perceptions of disabled
people. Evidence from the British Social Attitudes Survey 2009.
London, UK:
Office for Disability Issues. HM Government. Retrieved from
http://odi.dwp.gov.uk/docs/res/ppdp/ppdp.pdf.
atL80953_11_c11.indd 355 12/5/13 1:46 PM
http://odi.dwp.gov.uk/docs/res/ppdp/ppdp.pdf
Except for an unexplained 10% jump from 1998 to 2000 in the
percentage of people who felt there
was “a lot” of prejudice against the disabled, the numbers have
remained relatively steady in the
last 10 years. Eight out of 10 people believed that most people
would feel very or fairly uncom-
fortable if people said negative things about disabled people at
shops, among their friends, or at
work. However, 40% felt that disabled individuals were not as
productive as nondisabled people
some or most of the time. More people felt more uncomfortable
interacting with people with
learning or mental health difficulties than with those with
physical or sensory impairments.
Global Attitudes
A large literature review of the stigma relating to disabilities
found that the impact was remark-
ably similar across different countries, conditions, and public
health programs (van Brakel, 2006).

Another review (Lauber & Rossler, 2007) revealed that the
stigmatization of people with mental
illness is widespread in Asia, where the mentally ill are
sometimes considered dangerous and
aggressive. Their illness is often attributed to supernatural,
religious, or magical causes. The atti-
tude of mental health professionals and family members toward
people with mental illness is
often stigmatizing as well, which results in low rates of
treatment seeking in this population—that
is, if treatment is actually available.
With the increasing recognition that people are disabled by
environmental factors as well as
by physical or mental disorders, medically focused solutions are
giving way to more interactive
approaches. However, this attitude appears to be more prevalent
in developed countries relative
to developing countries, where people with disabilities are often
not considered potential mem-
bers of the work force. Globally, 80% to 90% of the disabled in
developing countries are unem-
ployed compared with 50% to 70% in industrialized countries
(United Nations, 2007).
Disability was addressed in an international context when the
United Nations’ Standard Rules on
the Equalization of Opportunities of Persons with Disabilities
connected disabilities with human
rights issues (U.N. General Assembly, 1993). This resulted in
the adoption of United Nations Con-
vention on the Rights of Persons with Disabilities (CRPD) in
2006. However, even though policies
and research indicate that attitudes toward disabled people have
improved overall, information,
education, training, and increased awareness are still needed at

the individual level to change
negative attitudes. In many countries, long-held cultural beliefs
still determine how persons with
disabilities are viewed and the extent to which they are included
or excluded in society. It is hoped
that as the countries and cultures change and learn from one
another, views about disability and
barriers to inclusion into society change as well.
Psychosocial Adaptation
In some countries, suffering from a chronic disease (particularly
mental illness) can mean stigma
and adverse psychosocial effects. Individuals can experience
disruptions in interpersonal relation-
ships, interaction with their physical environment, and
deterioration in psychological or emotional
health (Marini & Stebnicki, 2012). In some less developed
countries, having a mental illness is
still equated with involvement with black magic, and
individuals may be ostracized by their own
families. In addition to being stigmatized, pain, bereavement,
anxiety, frustration, and depression
are often part of the burden of chronic disease (Suhrcke, Fahey,
McKee, 2008). A Finnish study
reported that adults with persistent chronic illness, which limits
daily life, have more depression
and lower self-esteem than healthy individuals (Hurre & Aro,
2002).
atL80953_11_c11.indd 356 12/5/13 1:46 PM
Psychological health can improve with a community-based self-

management education program,
which successfully helped participants gain confidence by
becoming more self-sufficient (Brady et
al., 2013). In addition, psychosocial assessments should be part
of any diagnosis paradigm. Because
chronic stress is often a precursor to chronic illness,
consideration should be given for referring
patients to existing interventions and appropriate therapies. The
need is also great for increased
social inclusion—particularly of older people with chronic
diseases or cognitive impairments.
Debate as to the consequences of acceptance versus denial of a
chronic condition continues.
Research commonly reports that behaviors consistent with
denial lead to poorer illness manage-
ment and higher levels of sorrow and depression (Bechtold
Kortte, Wegner, & Chwalisz, 2003;
Carver et al. 1993; Jones 2003; Revenson & Felton, 1989).
However, just as much research chal-
lenges the association of acceptance with positive health
outcomes (Antoni & Gookin, 1988; Dean
& Surtees, 1989; Greer, Morris, Pettingale, & Haybittle, 1990;
Pettingale, Morris, Greer, Haybittle,
1985). The labels acceptance and denial may not be useful when
describing a person’s response
to chronic illness. It may be better to view chronic illness in the
context of a situation in which the
individual goes through shifting beliefs, perceptions,
expectations, attitudes, needs, and experi-
ences about the meaning of living with chronic illness (Alvani,
Parvn Hosseini, & Alvani, 2012).
Compounding the psychosocial difficulties are problems
associated with often being unemploy-
able and the impact this has on family income and personal

esteem—especially if the ill person is
the primary breadwinner. Australia, Singapore, and Thailand
have documented lower salary levels
for persons with CID compared with the general population
(Alvani et al., 2012). For those with
chronic conditions who try to remain productive, many feel
discriminated against because their
employers won’t agree to flexible hours to accommodate
treatment or because the workplace
isn’t adapted to the employee’s needs. Even more challenging is
the hidden bias in the hiring pro-
cess for people with disabilities (Shier, Graham, & Jones,
2009). Worries about loss of income can
lead to mental suffering and depression (McCabew & De
Judicibus, 2005). To combat these prob-
lems, a European directive adopted in 2010 prohibits any kind
of discrimination in employment,
including those with disability, in the 27 European Union (E.U.)
member states (Belgian Presidency
of the Council of the European Union, 2010).
The Medical Model of CID
In sharp contrast to the ICF model for understanding and
treating CID (discussed in Chapter 2) is
the medical model. This lens for viewing CID emphasizes
pathology and focuses on assessment,
treatment, and prognosis with the aim of returning the disabled
individual to society cured. In this
model, the problem related to the chronic illness resides within
the individual. So if he or she is
incurable, then by implication, that individual is dysfunctional,
because any limitation in functional
capacity is compared with the societal norm (Stucki, Gieza, &
Melvin, 2007). In the medical model,
the power to fix the problem lies within the medical community,
not the individual or society.

The Social Model of CID
The social model incorporates the philosophy of ICF, but
without the coding system. It views struc-
tures within society as the problem, more so than the individual.
The social model holds that a
complex form of “institutional discrimination” (including
poverty, inaccessible information and
transportation, discrimination in employment, prejudice, and an
overemphasis on the medical
model) prevents the disabled from achieving their full
functioning capacity. A comparison of the
thinking behind the two models is shown in Table 11.2.
atL80953_11_c11.indd 357 12/5/13 1:46 PM
Table 11.2: Comparison of medical and social models
Medical Model Thinking Social Model Thinking
Perception of individual Individual is faulty Individual is
valued
Typical courses of action Diagnosis Strengths and needs defined
by
self and others
Labeling Identify barriers and develop
solutions
Biases Impairment becomes focus of
attention

Outcome-based program is
designed
Approach to offering solutions Assessment, monitoring,
programs of therapy imposed
Resources are made available to
ordinary services
Effect on individual Ordinary needs put on hold Relationships
nurtured
Typical outcome Reentry if normal enough or
permanent exclusion
Diversity and inclusion
welcomed
Tendency toward progress Society remains unchanged Society
evolves
Source: Rieser, R. (2010). Disability equality: Medical
model/social model. Worldofinclusion.com. Retrieved from
http://www.worldof
inclusion.com/medical_social_model.htm. Copyright © World
of Inclusion, Ltd. Used by permission.
Using Bronfenbrenner’s Model to Better Understand CID
Bronfenbrenner’s ecological model of human development is
essentially an integrative model and
includes components similar to the ICF model. It explains how
environmental influences affect
an individual’s psychological development. As emphasized in
Chapter 1 and throughout this
text, Bronfenbrenner’s model includes five distinct system

levels that are at increasing distances
from the person: the microsystem, the mesosystem, the
exosystem, the chronosystem, and the
macrosystem. This model can also describe how individuals
interact with different levels of their
health care system.
Micro Perspectives
At the micro level, the ICF model sees the individual in a
personal context, taking into consider-
ation such factors as age, sex, personal attitudes about risk,
family support, and genetic endow-
ment. It also encourages a personalized medical approach to
care. This model holds that chronic
disease affects the individual’s level of consumption and capital
formation (savings), labor produc-
tivity and supply, and self-esteem, as well as education level
attained.
Meso Perspectives
At the meso level, the ICF model encourages patient and family
participation in health care plan-
ning and decision making. Patient-centered care encourages
integration of all the patient’s pro-
viders as part of a mesosystem.
atL80953_11_c11.indd 358 12/5/13 1:46 PM
http://www.worldofinclusion.com/medical_social_model.htm
http://www.worldofinclusion.com/medical_social_model.htm
CHAPTER 11Section 11.4 Economics of CID
Web Field Trip
A video produced by the WHO explains the impact of public

health on the economy and the impor-
tance of public health services that help individuals avoid
getting ill, protect them from diseases, and
promote healthy lives:
http://www.youtube.com/watch?v=8KrFLetj6CQ&list=PLL4_zL
P7J_mgigUiG9
MbXet9ttXgbSVQu.
Critical Thinking Questions
1. Do you agree or disagree with the narrator’s statement that
public health initiatives yield “more
health gain for much less cost?”
2. Do you think that public health programs are part of the
solution for CID, or could the public’s
money be better spent on other efforts?
Macro Perspectives
At the macro- (and exo-) system level, the ICF model is actively
engaged in policy and legislative
changes. These efforts are meant to increase access to care,
change social norms about chronic
disease, and modify behavior and environmental factors to
lessen the risk for disease, disability,
and death while enhancing the chances for health, mobility, and
longevity. Epidemiological and
other research data are used to track the prevalence and course
of chronic diseases, as well as to
modify it at the population level. U.N. initiatives to protect the
rights of the disabled are an exam-
ple of the macro sphere’s influence.
11.4 Economics of CID
The European medical community recognizes that to sustain

quality health care in the face of the CID epidemic new thinking
about the allocation of health care funding is necessary. Like
other services, health care spending has opportunity costs; that
is, the benefits of health
care must outweigh the cost to society. In other words, spending
on health care is economically
sustainable only up to the point at which the social cost of
health spending exceeds the value pro-
duced by that spending. It is generally accepted that the
healthier the society, the more productive
it is; thus, the economic benefits of a healthier society must be
incorporated into any calculation.
The indirect costs of CID go well beyond reduced income owing
to lost productivity. Indeed, the
costs of household members caring for ill family members, the
selling of assets to pay for medical
care, and the lost opportunities for the young who drop out of
school to care for ill adults are all
part of the economic burden of chronic illness.
In Europe, a major policy focus is to ensure equitable access to
health care regardless of the
ability to pay and to ensure quality and value for money spent.
Although this philosophy is firmly
established, the debate on how to achieve these objectives is
ongoing. Policy makers disagree on
whether to increase private or public funds to bridge the gap
between what is currently spent on
health care and future needs, which will include a burgeoning
demand for long-term care and care
for persons with chronic illness (Thomson, Foubister, &
Mossialos, 2009).
atL80953_11_c11.indd 359 12/5/13 1:46 PM

P7J_mgigUiG9MbXet9ttXgbSVQu
P7J_mgigUiG9MbXet9ttXgbSVQu
A variety of strategies has been
used to achieve the goals of
equitable access and value in
the health care sector in the
face of CID demands. These
include greater reliance on high-
technology assessment, efforts
to coordinate and direct strate-
gic resource allocation, provider
payment reforms that link pay
to performance, incentives to
enhance provider responsive-
ness, and the use of pooling: In
most European states, all public
funds for health care are col-
lected nationally, often gath-
ered into a single pool. Despite
the best efforts, however, as the
share of older people in the pop-
ulation increases and the share of the working population
decreases, the demand for health care
may exceed funding capacity and become unsustainable
(Thomson et al., 2009). This demographic
“time bomb” can be defused by either increasing revenue,
reducing services by shrinking cover-
age, or improving efficiency. After experimenting with various
service-delivery models, the Euro-

pean region still struggles to find the right formula.
Sources of Funding
Health care in Europe is financed by a combination of public
contributions (taxes and social insur-
ance) and private sources (e.g., health insurance, medical
savings accounts, out-of-pocket pay-
ments, and cost sharing). During the past 20 years, a major shift
has occurred from taxes to social
insurance as the dominate form of financing health care in many
of the newer member states of
central and eastern Europe. In these countries, the greatest
proportion of total expenditures on
health care are paid through public expenditures. Figure 11.5
compares the financial sources of
health care in 10 countries in the European region.
iStock/Thinkstock
The indirect economic costs of CID include the costs of
household
members caring for ill family.
atL80953_11_c11.indd 360 12/5/13 1:47 PM
Figure 11.5: Percentage of total expenditures on health in the
European region
by main contribution mechanism, 2005
Social insurance and taxes are primary sources of health care
financing for several European nations.

Note. OPP = out of pocket; “other” includes medical savings
accounts, cost sharing, and informal payments.
Source: Thomson, S., Foubister, T., & Mossialos, E. (2009).
Financing health care in the European Union: Challenges and
policy responses. European
Observatory on Health Systems and Policies (Figure 2.2b).
Copenhagen, Denmark: Retrieved from
http://www.euro.who.int/__data/assets/pdf_file
/0009/98307/E92469.pdf. Copyright . World Health
Organization (WHO). Used by permission.
Pooling covers the costs of those who need health care with the
contributions of healthy individ-
uals. In the U.S. private sector, the equivalent of pooling is
community rating in health insurance
(discussed in Chapter 10), in which risk is shared throughout
the insured population. In some
E.U. member states, although local taxes or individual health
insurance funds are used to finance
health care, measures are in place to reallocate these resources
to poorer regions, poorer mem-
bers, or members at higher risk of ill health (in the United
States, individual states run “high-risk
pools” to help cover the ill or uninsured). In Europe, unified
pools of publicly generated health
care resources enhance efficiency, provide more equitable
access, minimize duplication of pooling
efforts, and may even improve administrative efficiency
(Thomson et al., 2009).
France and Germany have increased their reliance on funding
health care with income not related
to earnings by placing tax allocations on employers to generate
more revenue. Also, centralized
systems of collecting funds improve collection standards and

increase revenue. Cost sharing also
encourages cost-effective patterns of use. (Most low-income
individuals and those with chronic
illness are exempt from this policy.) Note that, even in Europe,
where the public model domi-
nates, private insurance still flourishes in some markets, usually
serving wealthier and better-
educated groups.
The coming shift from acute care to long-term chronic care
requires a financing system with the
ability to enhance pooling, coordinate and direct resource
allocation, match resources to need,
shape the nature of supply, and create incentives to enhance
provider responsiveness (Thomson
et al., 2009).
Czech
Republic
OPP= out-of-pocket
“Other” includes medical savings accounts, cost sharing, and
informal payments
Denmark Finland France Germany Greece Ireland Spain Sweden
United
Kingdom
0
40
80
100

30
70
20
60
10
50
90
P
e
rc
e
n
t
Country
Tax
Social Insurance
Private Insurance
OOP payments
Other
atL80953_11_c11.indd 361 12/5/13 1:47 PM

http://www.euro.who.int/__data/assets/pdf_file/0009/98307/E92
469.pdf
469.pdf
Methods of Payment
In countries where health care is financed through a tax base,
supplies and services are purchased
through territorial entities. These take the form of regional or
local health authorities, or specially
created purchasing organizations such as Primary Care Trusts in
the United Kingdom. Some E.U.
member states (United Kingdom, Finland, Italy, and Portugal)
and some regions of Spain and Swe-
den have introduced purchaser–provider splits, a service
delivery model in which third-party pay-
ers are kept organizationally separate from service providers to
create competition among sup-
pliers (Tynkkynen, Keskimaki, & Lehto, 2013). Another way of
controlling costs is a combination
of capitation and FFS payments, which are most often used to
pay primary care providers. Spe-
cialists are paid on an FFS basis, in which social insurance
contributions are the basis of financing,
whereas specialists are often salaried employees in tax-financed
health systems. Hospital costs
are often budgeted. However, case-based payment is
increasingly used either to define budgets
or as a retrospective form of payment.
Incentives to Improve CID Care and Reduce Costs
Financial incentives can lead to quality improvements but only
when the needs of all stakeholders

are balanced (Leatherman et al., 2003). Several payment
methods have been tried in Europe to
incentivize payers to make appropriate decisions (Busse &
Mays, 2008). However, most methods
are related to the structure or process of care rather than the
individual, and the methods vary by
region. Table 11.3 displays the different categories of
incentives used in Europe and their targets:
the individual, the structure of care, the process of care, and the
outcomes.
Table 11.3: Incentives for improving chronic care in European
countries.
Financial Incentives
Targeting the
Individual
Targeting the Structure
of Care
Targeting Processes
of Care
Targeting Outcomes of
Care
• Piloting of “year
of care” payment
for the complete
package of chronic
disease management
that individuals with

chronic conditions
require, e.g., based
on validated “care
pathways” for
diabetes (Denmark,
United Kingdom)
• Per-patient bonus
for physicians for
acting as gatekeepers
for chronic patients
and for setting care
protocols (France)
• Bonus for DMP
recruitment and
documentation
(Germany)
• 1% of overall health
budget available
for integrated care
(Germany)
• Points for reaching
process targets
(United Kingdom:
GP contract)
outcome targets
(United Kingdom:
GP contract)
structural targets

(United Kingdom:
GP contract)
--- • Additional services (e.g. patient self-
management education) reimbursable only
if physicians and patients participate in DMP
(Germany)
---
Note: DMP = disease management program; GP = general
practitioner.
Source: Adapted from Busse, R., & Mays, N. (2008). Paying for
chronic disease care. In E. Nolte & M. McKee (Eds.), Caring for
people
with chronic conditions: A health system perspective, (195–
221). Maidenhead, U.K.: Open University Press. Copyright
World Health
Organization (WHO). Used by permission.
atL80953_11_c11.indd 362 12/5/13 1:47 PM
Although no conclusive European studies have shown the
effectiveness of these incentives, con-
clusions can be drawn from U.S. studies. One in particular
looked at the relationship between
financial incentives designed to improve health care quality and
a quantitative measure of health
care outcomes. The authors cautioned against focusing too
narrowly on incentivized tasks or areas
of quality that might lead to “gaming the system” without any

true improvements in care. They
believed that using mixed-payment approaches might lead to
better outcomes (Peterson, Wood-
ard, Urech, Daw, & Sookanan, 2006). Other researchers found
that financial incentives might be
good for individual providers but less effective for groups of
providers (Baron & Kreps, 1999). Also,
small- to medium-sized multidisciplinary teams that improved
six interrelated components—
self-management support, clinical information systems, delivery
system redesign, decision sup-
port, health care organization, and community resources—were
found to produce good outcomes
and reduce costs (Bodenheimer, Wagner, & Grumbach, 2002a,
2009b).
Only the U.K. National Health Service’s (NHS) contract for
GPs specifically includes incentive pay-
ments (pay for performance) that target the delivery of
particular outcomes (Roland, 2004; Smith
& York, 2004). Some evidence from a U.K. study suggests that
positive outcomes can be achieved
when incentives, coupled with outcomes and quality variables,
make up about 25% of practice
income (Campbell et al., 2007).
New health reforms in Germany encourage the allocation of
extra money for sickness funds when
patients with chronic diseases are enrolled in a DMP. Another
reform in Germany (Schang, 2009)
and the Netherlands (Van Ginneken, Busse, & Gericke, 2007)
provides extra financial incentives
for payers and insurers by taking individual morbidity criteria
into account.
For individual patients in Europe, relatively few financial

incentives exist. However, France and
Germany offer modest cost-sharing mechanisms when patients
with chronic diseases enroll in
DMPs. Also in France, patients who participate in and comply
with their DMP at every doctor’s
visit are exempt from copayments for chronic disease care.
Another strategy yet to be tried in
Europe is lowering premiums or contribution rates for patients
with chronic diseases who enroll
in a DMP. At the macro level, policy makers have been
encouraged to offer financial incentives for
integrating or linking chronic care programs, provide financial
incentives that encourage conti-
nuity of care, and align compensation plans across different
sectors for health professionals who
work together in the chronic care sector (Busse, Blümel,
Scheller-Kreinsen, & Zentner, 2010).
Because chronic care implies long-term care, benefits are often
seen only after many years of
treatment. When offering incentives to encourage providers to
provide high-quality care, pol-
icy makers must take this factor into consideration and assure
providers that their investment
is worthwhile.
Allocation of Care
Like the United States, an increasingly large percentage of the
European population consists of
older individuals, many with multiple chronic health problems;
therefore, the European model of
coverage for everyone may prove difficult to maintain.
Rationing of care may be necessary. Some
type of health care rationing is practiced by almost all
developed countries that offer universal
health care. These countries calculate the cost–benefit ratio of

treatments to ensure that scarce
medical resources are not wasted on expensive treatments that
have little chance of success. The
growing need for chronic care complicates the allocation of care
even further.
atL80953_11_c11.indd 363 12/5/13 1:47 PM
A chronic care model classifies patients by need and level of
intervention:
• Level 1 patients need support mainly for self-management.
• Level 2 patients, with multiple diseases or poor ability to
manage their own care,
need support from care teams, who use common protocols and
pathways.
• Level 3 patients require active disease management by medical
teams. (Economist
Intelligence Unit, 2013)
The RAND Evaluation (2013) study, which examined 51 sites
that use the chronic care model,
found a much better chance that patients in such facilities
received the correct therapy and expe-
rienced improved outcomes. For example, the duration of
hospital stays for patients with conges-
tive heart failure was reduced by an average of 35%.
In the United States, there are few restrictions on the use of
health care interventions, regardless

of cost or clinical effectiveness—at least for the moment.
Europe, in contrast, remains commit-
ted to universal coverage and equity to access, although the
limits of coverage and the extent
of services are subjects of debate. In both regions, caring for
patients with CID needs to evolve
away from the acute care model. Incentivizing doctors and
hospitals to spend more time treating
chronic illnesses is the first step. Some European countries are
already experimenting with such a
shift. For instance, the United Kingdom is experimenting with
incentive payment in which doctors
receive more money for keeping patients out of the hospital and
hospitals are penalized for high
rates of patient readmissions.
Human Resource Challenges
Human resources are central to every component of the
emerging social models of chronic care.
Developed countries are rethinking approaches to staffing and
utilization, bringing them more
in line with the chronic care model developed in the United
States (Wagner, 1998). This reor-
ganization is based on the fundamental differences between
acute and chronic care treatment.
Unlike acute conditions, chronic conditions are irreversible,
long-term, and require supervision
across many settings and different types of providers; they must
include a component of self-
management (Nodhturft et al., 2000).
Developing Integrated Services
Many developed countries are experimenting with an integrated
approach to chronic care that
involves practitioners across a spectrum of specialties, both
medical and social. This integration

requires a work force that can manage service transitions, have
a flexible attitude, and exercise
good communication and team-building skills.
In Sweden, district nurses provide the first line of assessment
for chronic care cases and direct
them to the appropriate resources. Then, county-owned health
centers provide services managed
by interdisciplinary teams of doctors, nurses, and other
providers at multiple sites. In England, pri-
mary care trusts and practice-based commissioning groups
coordinate chronic care through local
community providers of primary care. These providers include
GPs, nurses, and other community
staff. The trusts are also in charge of commissioning acute
hospital services.
atL80953_11_c11.indd 364 12/5/13 1:47 PM
Chronic shortages of medical staff, in particular doctors and
nurses, are already occurring. It is a prob-
lem that is only expected to get worse. Shortages occur not only
in developing countries, but also
in developed countries such as Australia, Canada, and the
United States. In the meantime, although
doctors are spending more of their time seeing CID patients
with both stable and uncontrolled ill-
nesses (Østbye et al., 2005), these patients are not necessarily
receiving quality health care.
New models of chronic disease management often incorporate a
patient self-management com-

ponent and involve the patient’s family in care decisions. This
model seeks to better respond to
individual needs and embodies a central role for the service user
and his or her family. It also
incorporates the patient’s perspectives and preferences in the
care process, while offering the
patient the educational and psychosocial support needed for an
effective care partnership. Figure
11.6 illustrates the relationship of the patient to the supportive
care networks, which corresponds
to the human ecological model of micro, meso, and micro
spheres of influence.
Figure 11.6: Patient-centered health care model
On a larger scale, it is important that a person’s health care
system and government are willing to understand
and support his or her health conditions.
Source: European Diabetes Leadership Forum (2012). The
diabetes epidemic and its impact on Europe. European Diabetes
Leadership Forum (p.22).
Copenhagen, Denmark: Author. Retrieved from
http://www.oecd.org/els/health-systems/50080632.pdf.
Copyright . OECD. Used by permission.
w
illing to listen, to change, and to be supp
ortiv
e o
f y
ou
r c

on
di
tio
n.A healthcare system, government,
and
pu
bli
c t
ha
t i
s
Society
Community
support for and understanding o
f yo
ur
co
nd
itio
n.
A
ccess to medical care and t
rea
tm

en
t,
an
d
su
pport in all aspects of yo
ur
co
nd
iti
on
.
E
m
otional and pra
cti
ca
l
Fa
mi
ly an
d Friends
You

Being able to cope
with your condition
and living a full,
healthy, and
productive life.
atL80953_11_c11.indd 365 12/5/13 1:47 PM
http://www.oecd.org/els/health-systems/50080632.pdf
Patient-Centered Service and Self-Care
When designing self-care systems, it is important
to recognize that the work force that cares for the
chronically ill is made up of three categories: formal
caregivers (those who provide institutional or pro-
fessional services), informal caregivers (those who
look after chronically ill and disabled relatives), and
self-care providers (the patients).
There are two main ways to reconfigure chronic
care: redefining existing roles and creating new
types of providers (Dubois, Singh, & Jimani, 2008).
Doctors also need to redefine their existing roles. A
new division of labor is needed in which tasks bet-
ter performed by nurses, pharmacists, community
workers, or trained laypersons are diverted from
the doctor. Many doctors spend too much time
performing administrative duties instead of treat-
ing patients. A transfer of responsibilities requires
a supportive policy framework with standards of
care and clear protocols in order to avoid uneven

levels of service and gaps in needed services. Other
types of health care professions can be enlisted to
coordinate and manage care programs, record per-
formance, monitor statistical outcomes, and assure
quality at every stage.
The chronic care model advocates that patients be as involved
as possible in designing and carry-
ing out their own care. It is hoped that patients who are in
charge of whether to take their medi-
cine, exercise, avoid harmful foods, and calculate their insulin
requirements are more likely to do
what is necessary to slow the progress of their disease (Dubois
et al., 2008).
Wavebreak Media/Thinkstock
The chronic care model encourages patients
to be involved in their own care.
Case Study: Live Well With COPD
The “Live well with COPD” program in Québec, Canada, is one
example of a patient-centered care
program. It allows the individual to assess his or her own needs,
determine how and by whom these
needs should be met, and adopt behaviors that are likely to
influence optimal physical, psychosocial,
and mental functioning. COPD centers consisting of
multidisciplinary teams offer courses about the
disease, its symptoms, and management; telephone follow-up;
and individual counseling. Patients are
encouraged to take full responsibility for self-management and
not pass this responsibility off to a third
party. At the same time, the program recognizes that the needs
of chronic care patients may include
help with chores such as shopping, cooking, and bathing.

Support in carrying out everyday tasks and personal contact
from nonmedical providers can improve
patients’ outlook and quality of life while relieving the burden
on the medical system and family
members. Also, the approach has been scientifically validated:
A randomized trial found that patients
enrolled in COPD self-management programs experienced
approximately 40% fewer hospital admis-
sions and emergency department visits for the exacerbation of
their condition (Bourbeau et al., 2003).
atL80953_11_c11.indd 366 12/5/13 1:47 PM
CHAPTER 11Section 11.5 CID and Government Policy
11.5 CID and Government Policy
As this text has explored, individuals in most countries suffer
from the same primary chronic diseases—cardiovascular
respiratory, cancer, and diabetes. In the United States and else-
where, the behavioral risk factors (e.g., tobacco use, overweight
and obesity, hyperten-
sion, alcohol abuse, and lack of exercise) are the same, though
their frequency varies from country
to country. Despite evidence of the link between these risk
factors and chronic illness, success in
addressing the challenges associated with these risks has been
patchy at the national and pan-
national (e.g., E.U.) levels.
Although recognized as essential, the transition from medical
care with an acute care focus to one
with a chronic care focus has been slow. The long-term,

complex nature of chronic care and treat-
ment, which is coordinated by a variety of health care
professionals with access to the necessary
drugs and equipment and which extends into the realm of social
care, has confounded traditional
top-down, government-led responses. Efforts to integrate
policies, finances, and provider services
to suit the needs of patients and caregivers and facilitate the
input of community and private
expertise have been sluggish. Most countries are experimenting
with policies to prevent disease
and spur early detection. DMPs and other novel approaches to
financing and staffing are being
tried, but they are harder to implement.
Four Health Care Systems
Four main health care systems are in use today: the Beveridge
model, the Bismarck model, the
national health insurance model, and the out-of-pocket model.
All four models can be seen in the
United States health care system (Physicians for a National
Health Program, 2010).
The Beveridge Model
In the single-payer Beveridge model, health care is provided
and financed by the government
through taxes. Most of the system is owned and controlled by
the government, which has greater
control over costs. United Kingdom, Spain, most of
Scandinavia, and New Zealand are examples of
countries using the Beveridge model.
The Bismarck Model
The Bismarck model uses an insurance system in which the
insurers are called “sickness funds.”
Although these funds resemble health insurance in the United

States (they are usually financed
jointly by employers and employees through payroll deduction),
the insurance companies cannot
make a profit or deny anyone coverage. Instead, Bismarck-type
health insurance plans are non-
profit systems required to cover everyone. Germany, France,
Belgium, the Netherlands, Japan,
Switzerland, and, to a degree, Latin American countries use the
Bismarck model.
atL80953_11_c11.indd 367 12/5/13 1:47 PM
The National Health Insurance Model
Founded in Canada, the national health insurance model has
elements of both the Beveridge and
Bismarck models. It uses private-sector providers, but they are
paid from a government-run insur-
ance program that every citizen contributes to. These universal
insurance programs tend to be
cheaper and simpler to administer compared with the U.S. “for
profit” model. Taiwan and South
Korea have adopted this model.
The Out-of-Pocket Model
The out-of-pocket model is practiced by most of the nations that
are too poor or disorganized to
provide any kind of mass medical care. To put it bluntly, this is
a purely market-driven system in
which the wealthy get medical care and the poor stay sick or die
prematurely.
Prevention Strategies for CID

Many countries are moving from an approach to chronic disease
that focuses on just treatment to
an approach that focuses on early detection, prevention, and
support for lifelong well-being. Pre-
vention strategies function at three levels: primary (removing
the cause), secondary (identifying
the disease at early stages when it can be treated), and tertiary
(activities intended to cure, ame-
liorate, or compensate for the disease). The approaches vary
according to the health care system,
cultural views, and the dominant political opinions of each
region. The amount of community,
business, and individual responsibility also depends on views
about the role of institutions and
individual autonomy (Busse & Schlette, 2003). Scandinavian
policies, for example, attach consider-
able importance to environmental factors and social conditions.
Other countries, such as France,
Germany, and the United States, focus more on the individual’s
attitude to risk factors such as
tobacco, alcohol, and nutrition (Busse, Zentner, & Schlette,
2006).
Case Study: Success Stories From Finland and Poland
In the 1970s, heavy tobacco use, high-fat diets, and low
vegetable intake were the norm in Finland.
Finland also had the highest death rate from cardiovascular
disease. However, death rates in men with
heart disease fell by 65% largely because of several factors:
community-based interventions, legislation
banning tobacco advertising, the introduction of low-fat dairy
and vegetable oil products, changes in
how farmers were paid (linking payment for milk to its protein
level rather than fat content), and incen-
tives for communities achieving the greatest cholesterol
reduction (Vartianinen et al., 2000).

(continued)
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Tobacco Control
Many European countries enact tobacco-control policies that
increase prices, levy taxes, educate
the public, restrict sales, ban smoking in public places, and
offer behavioral assistance to quit
(Busse & Schelette, 2007). Ireland, Italy, Malta, New Zealand,
Norway, Singapore, and Sweden
have introduced a complete ban on smoking in public places and
at work. Russia, which has one
of the highest rates of smoking in the world, banned smoking in
many public places in June 2013.
Similar regulations have been introduced in other countries,
including Australia, the Czech Repub-
lic, England, Finland, Germany, Hungary, Portugal, Scotland,
the Philippines, and Spain. The Phil-
ippines has reported significant drops in the number of teenage
smokers and a drop from 23% to
14% in the number of adult smokers in Singapore (WHO, 2005).
Case Study: Success Stories From Finland and Poland
(continued)
Figure 11.7: Heart disease and lung cancer death rates among
men aged
30 years and older in Finland
Finland had the highest death rate from cardiovascular disease.

Source: World Health Organization. (2005). Preventing chronic
diseases: A vital investment (p.93). Geneva, Switzerland:
Author. Copyright . World
Health Organization (WHO). Used by permission.
One of the most dramatic declines in death rates from heart
disease occurred in Poland in the 1990s.
The decline was attributed to the replacement of dietary
saturated fat with polyunsaturated fat. The
trend was associated with a simple top-down government
intervention: the removal of price subsidies
on butter and the availability of cheaper vegetable oils
(Zatonski & Willett, 2005).
1950
0
400
800
A
g
e
-s
ta
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d
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rd
iz

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d
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10
0
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0
0
600
200
300
500

100
700
Year
1960 1970 1980 1990 20102000
Heart disease
Lung cancer
atL80953_11_c11.indd 369 12/5/13 1:47 PM
Taxation can reduce smoking as well as raise reve-
nue for health promotion and disease prevention
programs, as shown in the Australian state of Vic-
toria and subsequently in several other countries,
including Thailand. A 10% price increase in tobacco
products has been shown to reduce demand by 3%
to 5% in high-income countries and by 8% in low-
and middle-income countries (WHO, 2005).
Anti-Obesity and Hypertension Programs
Obesity prevalence can be modified through pub-
lic information and education and by targeting
children and adolescents, taxing unhealthy food,
planning the urban environment, and prohibiting
certain foods (Novotny, 2008). Higher prices have
been shown effective for controlling alcohol and
soft-drink consumption, while subsides can encour-
age healthier food choices (WHO, 2005).
Programs targeting at-risk youths and adults with

high blood pressure and aimed at increasing their
participation in physical activity have succeeded
in Brazil. For example, education sessions and per-
sonalized advice given to a group of people with high blood
pressure and diabetes resulted in
a 96% increase in regular physical activity (Matsudo et al.,
2004). Similar programs for weight
loss, dietary control, physical activity, and moderate alcohol
consumption are being combined to
control hypertension and reduce the incidence of ischemic heart
disease (Chobanian et al., 2003;
Novotny, 2008). Holistic approaches to preventing hypertension
involve an array of stakeholders:
representatives of local government, the food industry, cultural
groups, schools, sports clubs, and
public and private health institutions. They all work together to
promote healthy behaviors in
schools, families, and communities; change urban design to
support healthier and more active
lifestyles; strengthen community leadership and action; and
support primary care prevention and
early intervention (WHO, 2005).
Vaccination and Screening Programs
Chronic disease prevention programs in Europe often use
vaccinations. For example, the human
papilloma virus vaccine to prevent cervical cancer is now part
of immunization programs in Austria,
Germany, France, Italy, Belgium, Luxembourg, Norway,
Sweden, Switzerland, and the United King-
dom (Arun, 2007).
Screening programs are used for early detection of cancers. In a
number of Latin American coun-
tries, cervical cytology screening programs have been in place

for more than three decades and
have resulted in significant decreases in the incidence of
cervical cancer (Sankaranarayanan,
Budukn, & Rajkumar, 2001). The U.K. government formulated a
national cancer plan in 2000,
specifying targets and standards for prevention that include a
national screening program for
colon cancer.
Thanassis Stavrakis/Associated Press
Many European countries are enacting
tobacco-control policies as a form of disease
prevention.
atL80953_11_c11.indd 370 12/5/13 1:47 PM
Disease Management
CID management approaches vary across and within countries.
They can take the form of DMPs,
nurse-led care, integrated care composed of a multidisciplinary
team, or managed discharged.
DMPs focus on specific diseases such as diabetes, asthma, and
cancer, to guide patients through
the health care system. The National Sickness Fund in France
piloted a DMP called Sophia, tailored
to the needs of diabetic patients and relying mainly on nurses
working in call centers (Bourgueil
& Or, 2010). By the end of 2010, approximately 62,000 patients
had joined the program. (No out-
come data have been reported.)

In the United Kingdom and the Netherlands, nurse practitioners
perform some tasks (e.g., pre-
scribing certain medications and administering certain
treatments) that traditionally fell within
the doctor’s realm. In Germany, community nurses play a
similar role, and they also run clinics in
Hungary, Italy, and the Netherlands. Integrated approaches—
being tried in the United Kingdom,
Canada, and New Zealand (Novotny, 2008)—use clinical care
systems as part of a broader, multi-
faceted approach to disease management and self-care. These
approaches, which often include a
multidisciplinary team led by a GP, empower patients and foster
enhanced communication among
patients, care providers, funders, and treatment suppliers. They
also strive to streamline admin-
istration, care payment mechanisms, care management, and
health systems as well as enhance
skills, education, and information-sharing among all
stakeholders (Nolte, 2011; Novotny, 2008).
Primary care traditionally provided by solo-practice is still in
operation in many countries (Austria,
France, and Germany). Some now include enhanced functions in
patient self-management, which
may involve the patient in developing a treatment plan and
setting goals under the supervision of
a doctor.
Community-based intervention seems to be a buzzword in many
countries. The city of Bogotá,
Colombia, has built parks, bike paths, and pedestrian walkways
dedicated to leisure activities
(WHO, 2005). In Tianjin, China, a project was launched in 1984
that included training new health
personnel, improving health education and counseling, and

making environmental changes to
reduce chronic disease risk factors at the community level (Tian
et al., 1995). A community-based
rehabilitation program that included mobility training and
training to perform normal daily activ-
ities improved quality of life in permanently blind patients in
rural south India by 95% (Vijayaku-
mar, John, Datta, Thulasiraji, & Nirmalan, 2004). Guidelines
and protocols, often developed by
international bodies of doctors, provide decision-making
support for these programs. Elements of
disease management are outlined in Table 11.4.
Table 11.4: Key elements of disease management
• Comprehensive care: multidisciplinary care for entire disease
cycle.
• Integrated care, care continuum, and coordination of the
different components.
• Population orientation (defined by a specific condition).
• Active client–patient management tools (e.g., health
education, empowerment, self-care).
• Evidence-based guidelines, protocols, and care pathways.
• Information technology, system solutions.
• Continuous quality improvement.
Source: Velasco-Garrido, M., Busse, R., & Hisashige, A.
(2003). Are disease management programmes (DMPs) effective
in improving quality
of care for people with chronic conditions? Copenhagen,

Denmark: WHO Regional Office for Europe (Health Evidence
Network report).
Retrieved from http://www.euro.who.int/document/e82974.pdf.
permission.
atL80953_11_c11.indd 371 12/5/13 1:47 PM
http://www.euro.who.int/document/e82974.pdf
Outcomes
Early intervention to reduce risky behaviors is seen as the best
way to reduce the consequences
of those behaviors, for example, cardiovascular disease,
diabetes, chronic respiratory disease,
and cancer.
Anti-Obesity Programs
The Ensemble Prévenons l’Obésité Des Enfants (EPODE) is a
European prevention program aimed
at changing the environment and facilitating the adoption of
healthier lifestyles in everyday life to
prevent childhood obesity. It involves political commitment, as
well as social and support services
at the community level. It is the largest program geared toward
childhood obesity and is active in
more than 17 countries, including Mexico and Australia. Few
studies have reported outcomes to
date; however, a small study conducted in France reported that
community-based programs like
EPODE were significantly more effective than school-based
programs in reducing obesity among
school-aged children (see Figure 11.8). This study did not

report that EPODE programs reduce obe-
sity, only that interventions targeting a variety of population
groups can have synergistic effects on
overweight prevalence.
Figure 11.8: Impact of community versus school programs on
weight reduction
in children
Community-based programs were more effective in reducing
obesity among school-aged children.
Source: Romon, M., Lommez, A., Tafflet, M., Basdevant, A.,
Oppert, J. M., Bresson, J. L., . . . Borys, J. M. (2009).
Downward trends in the prevalence of
childhood overweight in the setting of 12-year school- and
community-based programmes. Public Health and Nutrition, 12,
1735–1742.
1992
0
8
20
18
C
h
il
d
h
o

o
d
o
b
e
s
it
y
p
re
v
a
le
n
c
e
(
%
)
12
4
16

6
10
2
14
Years
2004
School-based approach Community-based approach
NS; p = 0.7
NS
CT=comparison towns; FLVS=Fleurbaix Laventie Villa Santa
Study; NS=not significant
p < 0.0001/FLVS 2004
p < 0.0001/FLVS 2000
2000
12.6%
17.8%
8.8%
14.3%
11.4%

CT
FLVS
atL80953_11_c11.indd 372 12/5/13 1:47 PM
Although the promoters of such programs view scientific
evaluation as important, they do
not strictly follow evidence-based standards. They caution that
evaluation is expensive and
time-consuming and add that lessons may be garnered from
deeper evaluations. They call for an
optimum balance between scientific standards and feasibility. In
short, they hold that the social
implications of community-based interventions should take
precedence over statistically signifi-
cant evidence that the program reduces obesity (Borys et al.,
2013). Other studies cited by Borys
et al. include a pilot study using EPODE methodology, which
reported a 9% decrease in the num-
ber of overweight and obese children after four years, and
another reporting a 2% decrease in
overweight nursery school children during a one-year period
(Borys, 2010; EPODE International
Network, 2012).
Tobacco Control
The European Network for Smoking Prevention (ENSP) is an
international organization whose
purpose is to coordinate action among organizations active in
tobacco control in Europe by sharing
information and experience and through coordinated activities
and joint projects. The programs

use price increases, bans, subsidies for treatment, media
campaigns, and package warnings to
reduce smoking prevalence. The effects of antismoking
measures supported by ENSP have been
very successful, as seen in Table 11.5. Whether ENSP programs
indirectly reduce chronic diseases
has not been reported, however.
Table 11.5: Effects of antismoking measures on smoker
prevalence
Measure Effect on smoker prevalence
Price increase by 10% Decline by 4% in countries with high per
capita
income
Ban on smoking at work Decline by 5–10%
Bans on smoking in pubs, restaurants, and other
public places
Decline by 2–4%
Advertising ban Decline by 6% if ban is absolute
Health warning on cigarette packs In the Netherlands, 28% of
all 13 to 18 year
olds said they smoked less as a result of health
warnings.
In Belgium, 8% of those asked said they smoked
less because of warnings.
Media campaigns Percentage of smokers declines by 5–10%,
depending on how the campaigns are targeted at

specific groups.
Withdrawal measures; subsidies for treatment Decline by 1–2%
after two years, depending on
the people registered.
Source: Thomson, S., Foubister, T., & Mossialos, E. (2009).
Financing health care in the European Union: Challenges and
policy responses.
European Observatory on Health Systems and Policies (Table
5.1). Retrieved from
http://www.euro.who.int/__data/assets/pdf_file/0009
/98307/E92469.pdf. Copyright . World Health Organization
(WHO). Used by permission.
atL80953_11_c11.indd 373 12/5/13 1:47 PM
469.pdf
469.pdf
CHAPTER 11Section 11.6 Innovations in CID
Nurse-Led Care
Primary care nurses with enhanced skill sets provide care for
chronically ill patients traditionally
treated by family doctors (Dubois et al., 2008). Nurse
specialists (e.g., those focusing on COPD or
diabetes) have been effective in improving self-care, quality of
life, and patient satisfaction (Hor-
rocks, Anderson, & Salisbury 2002; Kinnersley, Anderson, &
Parry 2000; Singh, 2005; Vrijhoef, Die-
deriks, & Spreeuwenberg 2000; Vrijhoef, Diederiks,
Spreeuwenberg, & Wolffenbuttel, 2001). As

an example, nurse-led heart-failure clinics in Sweden have been
associated with better education,
better treatment, and social support; improved survival and self-
care; and reduced hospital care,
events, and deaths (Cline, 2002; Strömberg et al., 2003).
Disease Management
The effectiveness of chronic disease management has been
examined in a number of studies, with
mixed results (Weingarten et al., 2002). Those using provider
education, feedback, or reminders
were associated with significant improvements in provider
adherence to guidelines. Appropriately
evaluated DMPs improved the quality of care, as measured by
the provider’s increased adherence
to evidence-based standards and effective disease control
(Velasco-Garrido et al., 2003). A review
of 317 studies reported that DMPs improved the process of care
and disease control, though not
health outcomes or utilization rates. An exception was DMPs
that reduced hospitalization rates
among patients with congestive heart failure and increased
outpatient care and prescription drug
use among patients with depression (Mattke, Seid, & Ma, 2007).
Although DMPs seem to improve quality of care, Velasco-
Garrido et al. believed that more sup-
porting evidence based on scientifically sound methods was
needed. Overall, the evidence on
DMPs remains questionable, and cost-based studies are
inconclusive. A few studies have sug-
gested that population-based interventions improve patient care,
but none of these studies were
randomized (Fireman, Bartlett, & Selby, 2004; Sidorov et al.,
2002; Villagra & Ahmed, 2004). Fur-
ther, the medium- and long-term impact of DMPs has not yet

been studied satisfactorily (Nolte &
McKee, 2008a).
Integrated Care
Supportive evidence varies depending on the model of
integrated care study (Nolte & McKee,
2008b), and large-scale, population-based studies are lacking.
Some research has found one or
more components of integrated care beneficial, but the evidence
does not show whether the
whole model is needed to achieve the same benefits (Singh &
Ham, 2006). Implementation
remains a key challenge. Evidence for cost effectiveness is also
controversial. Regional differences
in cost structures and the type and burden of chronic disease can
influence cost outcomes. So far,
no conclusive evidence has shown the cost effectiveness of
using new specialties, such as nurse
practitioners or case managers.
11.6 Innovations in CID
Innovations in research, pharmaceuticals, personalized
medicine, and technology (see “E-Health” in this chapter) can
help address problems associated with CID and advance patient
care.
atL80953_11_c11.indd 374 12/5/13 1:47 PM
Research
The European Union is undertaking research projects that
address the problem of CID from a

number of angles, including cost-effective behavioral
modification, health prevention and pro-
motion, screening, compliance, and integrated care. More
research into the processes underlying
chronic disease prevalence and incidence is also in progress.
Although often lacking in this area,
research with prospective, randomized controlled trial protocols
make a better approach than
observational studies for generating empirical evidence on
health service delivery. Such proto-
cols allow different programs to be compared, and they compare
endpoints that are relevant to
patients’ lives (Beyer, Gensichen, Szeceseny, Wensing, &
Gerlach, 2006; Sawicki, 2006).
Pharmaceuticals
New drugs and medical devices are essential to advance the
prevention and treatment of
chronic disease. New antihypertensive drugs, insulin,
antidepressants, anti-inflammatories, and
inhaled steroids, which were unknown at the end of the 1980s,
have been developed to target
the disease process.
A larger problem than the need for new drugs or devices is
patient compliance. Only about 50%
of patients in developed countries adhere to their treatment. The
proportion of U.S. patients
adhering to their hypertension medication is reported to be a
paltry 51% (“Critical Overview of
Antihypertensive Therapies,” 2000); in developing countries,
the rates are even lower (Guo, He, &
Jiang, 2001; van der Sande et al., 2000). Similar patterns of
poor compliance have been reported
for other conditions such as depression (~ 40% noncompliance;
Demyttenaere, 1998). In Australia,

adherence to prescribed medication for asthma is only 43%, and
for preventive medication, it is
28% (Reid, Abramson, Raven, & Walters, 2000).
Fixed-dose combination therapy (polypill) is being offered as a
way to increase medication com-
pliance for a variety of illnesses. This dosing method improves
compliance by reducing pill burden
(Bangalore, Kamalakkannan, Parker, & Messerli, 2007). Other
approaches to improve compliance
include behavioral, educational, and social support
interventions.
Personalized Medicine
Another area of great interest is personalized medicine, which
selects drug therapy based on
individual genetic makeup. Personalized medicine uses
optimized drug therapy to achieve maxi-
mal response in a subset of individuals. It promises fixed doses,
milder side effects, and improved
outcomes for qualified patients with chronic illnesses (Lewis,
2005). In pursuit of personalized
medicine, the Human Genome Project has led to new drug
discoveries that have been applied
in many areas of cancer therapy. As it becomes more
widespread, the use of personalized medi-
cine will force policy makers at the government and regulatory
levels, as well as payer organiza-
tions (e.g., insurance companies), to rethink how to organize
drug licensing and reimbursement
(Shane, 2007).
New Provider Settings
New types of provider specialties, settings, and qualifications
are emerging in many countries.
Group practices, medical polyclinics, and nurse-led clinics that

are more patient oriented and cost
effective are being established (Busse & Schlette, 2003). In
Canada, for example, new chronic
atL80953_11_c11.indd 375 12/5/13 1:47 PM
care models in which doctors work within teams comprising
nurses, social workers, psychologists,
dieticians, midwives, and physiotherapists are being developed.
The purpose is to create a multi-
disciplinary, well-coordinated, 24-hour accessible system
(Torgerson, 2005). In Germany, polyclin-
ics were opened with GPs, specialists, and other health
professionals in 2004 (Busse et al., 2006).
The management of many chronic diseases has been moving
progressively to nurse-led clinics in
the United Kingdom, the Netherlands, and Scandinavia (Buchan
& Calman, 2005; Nolte & McKee,
2008a). Some of these clinics specialize in diabetes,
hypertension, allergy, asthma, COPD, mental
illnesses, and heart failure (Karlberg, 2008). These
developments create new career opportunities
for nurses and reduce health care costs.
As discussed earlier, DMPs attempt to coordinate resources
across the health care delivery system.
They are similar to integrated care systems, except they include
social workers. Most DMPs have
three main features: a knowledge base, a delivery system with
coordinated care, and a continuous
improvement process for a specific disease within a specific

population (Hunter & Fairfield, 1997).
Disease management is a system that tries to deliver
coordinated care—organized according to
scientific evidence—throughout the clinical course of a chronic
illness. Patients are consulted on
care-management decisions.
In Sweden, the Swedish Elderly Reform used the concept of
integrated delivery systems to decen-
tralize health care and coordinate activities while it reduced
redundancy (Andersson & Karlberg,
2000). “Chains of care,” as they are called, regard patients as
partners instead of objects (Åhgren,
2003). County councils are responsible for organizing health
care in this instance. The chain-of-
care system has been slow to develop, however, because of
resistance from doctors and health
care managers (Åhgren & Axelsson, 2007).
In some instances, DMPs are replaced by improved
comprehensive integrated care models.
In 2005, the United Kingdom launched a health and social care
model to improve the quality
and accessibility of care for people with chronic conditions and
to contain or reduce the associ-
ated costs (de Silva & Fahey, 2008). It was based on two
chronic care models used in the United
States—the Kaiser Triangle and the Evercare model—and
featured nurse-led clinics, specialist
nurses called “community matrons,” and case management. This
model outlined how to identify
people with chronic conditions and stratify their care needs. It
used a systematic approach to link
health and social care with service users and caregivers, and
used local methods to support self-
care. Evaluation of the program is ongoing, but one study’s

SOC313 Introduction to the Miller Family Sarah (40 y.docx

SOC313 Introduction to the Miller Family Sarah (40 y.docx

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