The document discusses efforts by the US Department of Health and Human Services (HHS) to address the growing challenges posed by multiple chronic conditions. HHS released a 2010 strategic framework with 4 goals: 1) foster health system changes like accountable care organizations and medical homes, 2) empower individuals through self-management programs, 3) equip clinicians with guidelines and training, and 4) enhance research. Since then, HHS has made progress in areas like expanding self-management programs, testing new care models, establishing payments for non-face-to-face care management, and increasing focus on comorbidities in clinical trials and guidelines. However, more accelerated efforts are still needed across all goals to better meet the needs of the growing multiple

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Optimizing Health for Persons With Multiple
Chronic Conditions
The challenges for the US health care system of high
healthcarecostsandpoorhealthoutcomesinindividu-
alswithmultiple(2ormore)concurrent,chroniccondi-
tionshavebeenwelldocumented.1,2
Estimatesarethat
morethanone-quarterofalladultshavemultiplechronic
conditions3
; in addition, more than two-thirds of Medi-
care fee-for-service beneficiaries have multiple chronic
conditions, with 14% having 6 or more common
conditions.4
Recently,theCentersforMedicare&Med-
icaid Services (CMS) released new data resources on
chronicconditionsamongMedicarefee-for-serviceben-
eficiaries to better define the burden of chronic condi-
tions among beneficiaries and the implications for the
US health care system.
In response to this public health challenge, the US
Department of Health and Human Services (HHS) re-
leased its report “Strategic Framework on Multiple
Chronic Conditions” in 2010. The strategic framework,
developed with private sector input, provides HHS and
itspartnerswitharoadmapforimprovingthehealthsta-
tus of persons with multiple chronic conditions across
4 overarching goals5
(Box). Within the first few years of
implementation,thestrategicframeworkhasledtothe
following selected actions and continues to offer addi-
tional opportunities for further collaboration.
Goal 1: Foster Health Systems Change
New Models of Care
TheAffordableCareActhasacceleratedeffortstocoordi-
nateandmanagecareforindividualswithmultiplechronic
conditionsthroughbroad-basedmodelssuchasaccount-
able care organizations and patient-centered medical
homes. In addition, specific models focused on the mul-
tiplechronicconditionspopulationarealsobeingtested
byCMS,suchastheIndependenceatHomedemonstra-
tion,whichisprovidinghome-basedprimarycareto8000
frailMedicarebeneficiarieswithmultiplechronicconditions
andfunctionallimitations.Inaddition,theMedicaidHealth
Homestateplanoptiontocoordinatetheprimary,acute,
behavioral,andlong-termcareofindividualsprimarilywith
multiplechronicconditions,manyofwhomhaveaserious
mental illness, has been adopted by 15 states and serves
more than 1 million Medicaid beneficiaries at the time of
this publication. Approximately 40 000 Medicare-
Medicaidenrollees,agrouptraditionallywithhighpreva-
lenceratesofmultiplechronicconditions,arecurrentlyen-
rolled in new integrated care models in 6 states.
Payment for Non–Face-to-Face
Care Management Services
Inits2014physicianfeeschedulefinalrule,CMSfinalized
regulationstostartin2015toestablishseparatepayments
formanagingthecareofpatientswithmultiplechroniccon-
ditionsoutsideofaface-to-facevisit.Thisdecisionrecog-
nizestheimportanceofcare-managementservicesforpa-
tientswithmultiplechronicconditions,particularlythose
mostvulnerabletopooroutcomesandhighcosts.
Goal 2: Empower Individuals
Evidence-Based Self-management Programs
In 2010, the Administration on Aging awarded approxi-
mately$30millioningrantsfromAmericanRecoveryand
ReinvestmentActfundstoexpandparticipationinStan-
fordUniversity’sChronicDiseaseSelf-ManagementPro-
gram.Todate,185 000olderUSresidents,thevastma-
joritywithmultiplechronicconditions,haveparticipated
in a chronic disease self-management program. These
programshavebeenshowntoimprovesymptoms,pre-
vent exacerbations of illness, and decrease emergency
department visits. In 2013, CMS issued a report to Con-
gress mandated by the Affordable Care Act on evaluat-
ing community-based wellness and prevention pro-
grams such as chronic disease self-management
programsfortheireffectsonMedicarebeneficiaries.Ret-
rospective analyses suggest potential cost savings for
certain physical activity, falls prevention, and self-
management programs.
Goal 3: Equip Clinicians
Clinical Practice Guidelines and Quality Measures
In2012,theInstituteofMedicineandHHSconvenedexpert
stakeholderstodiscussintegratinginformationoncomor-
biditiesinclinicalpracticeguidelinesforspecificconditions.
Sincethattime,anumberofprofessionalsocieties,includ-
ingtheAmericanCollegeofCardiology,AmericanHeartAs-
sociation, and the American Society of Clinical Oncology,
havepublishedguidelineswithcomorbidity-specificinfor-
mationtoassistphysiciansandotherfront-linecliniciansin
betterunderstandingthecomplexityoftheirpatientpopu-
lations.Inaddition,in2012,theNationalQualityForum,with
fundingfromHHS,releasedamultiplechronicconditions
measurementframeworktoprovideguidancetomeasure
developersastheygenerateappropriatemeasuresforcli-
nicianstreatingindividualswithmultiplechronicconditions.
Education and Training
In2013,theOfficeoftheAssistantSecretaryforHealth,
in conjunction with the Health Resources Services Ad-
ministration, launched an interprofessional health care
education and training initiative to inform undergradu-
ate,graduate,andcontinuingeducationcurriculaoncore
competenciesessentialtocaringforthemultiplechronic
conditions population. The resources developed are
slated to be released by the end of 2014 and then dis-
seminated to training programs by the Health Re-
sources Services Administration.
VIEWPOINT
Anand K. Parekh, MD,
MPH
Office of the Assistant
Secretary for Health,
US Department of
Health and Human
Services, Washington,
DC.
Richard Kronick, PhD
Agency for Healthcare
Research & Quality, US
Department of Health
and Human Services,
Washington, DC.
Marilyn Tavenner, RN,
MHA
Centers for Medicare &
Medicaid Services, US
Department of Health
and Human Services,
Washington, DC.
Corresponding
Author: Anand K.
Parekh, MD, MPH,
Office of the Assistant
Secretary for Health,
US Department of
Health and Human
Services, 200
Independence Ave SW,
Washington, DC 20201
(anand.parekh@hhs
.gov).
Opinion
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2. Copyright 2014 American Medical Association. All rights reserved.
Goal 4: Enhance Research
External Validity of Clinical Trials
In2013,aftercommissioningawhitepaperontheissue,theUSFood
and Drug Administration (FDA) announced a new internal policy to
morecloselyexaminepopulationsincludedinclinicaltrialsbyspon-
sors of new drug applications to discourage unnecessary exclu-
sions and to encourage the inclusion of individuals with comorbidi-
ties. The FDA stated that its goal is to ensure that products coming
to market will be safe and effective for all members of the public,
and clinical trials that reflect the real-world population are an im-
portant part of achieving this goal.
Patient-Centered Outcomes Research
In 2010, the Agency for Healthcare Research & Quality awarded
approximately $20 million in grants from American Recovery and
Reinvestment Act funds to increase research on the influence of
comorbidities on the treatment and management of particular
chronic conditions. As a result of this opportunity, the agency
expanded its nationwide multiple chronic conditions research net-
work to 45 grantees from which a body of research has emerged in
areas including comanagement of commonly concurrent condi-
tions, guidelines for preventive services, and medication manage-
ment in patients with multiple chronic conditions. In addition, the
National Institutes of Health has funded and announced 7 new
funding opportunities since 2010 focused on the multiple chronic
conditions population. One of the most important of these is part
of its health care systems research collaboratory to fund demon-
stration projects for pragmatic clinical trials focused on manage-
ment of multiple chronic conditions.
Critical Next Steps
Although HHS and its partners have made incremental progress in
addressingchronicconditionsthroughuseofamultiplechroniccon-
ditions lens, there is an imperative to accelerate efforts across all of
the goals.
First,moredeliveryandpaymentmodelswillneedtofocusspe-
cificallyonsubsetsofthemultiplechronicconditionspopulationthat
are at highest risk for poor outcomes and high costs.6,7
Models that
are shown to be effective and efficient should be widely dissemi-
nated and implemented.
Second, evidence-based community prevention and wellness
programs currently reaching hundreds of thousands of individuals
should be expanded further through partnerships with health care
entitiestoreachtensofmillionsofindividualswithmultiplechronic
conditions.
Third, the multiple chronic conditions population needs to be
an area of focus for research on patient-centered outcomes to in-
formthedevelopmentoffutureclinicalpracticeguidelines,bestprac-
tices, and quality measures.
HHSwillcontinuetoreleasedataonchronicconditionssohealth
leaders and innovators can better identify specific populations and
geographicareasinwhichmorecoordinatedandcomprehensiveap-
proaches to prevention and treatment can be delivered to persons
withmultiplechronicconditions.Progressintheseareaswillbecriti-
caltoimprovethehealthstatusofindividualswithmultiplechronic
conditions and to move toward a more effective and sustainable
health care system.
ARTICLE INFORMATION
Published Online: August 18, 2014.
doi:10.1001/jama.2014.10181.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Additional Contributions: We acknowledge
Howard K. Koh, MD, MPH, Office of the Assistant
Secretary for Health, US Department of Health and
Human Services; Richard A. Goodman, MD, MPH,
Centers for Disease Control and Prevention, US
Department of Health and Human Services; and
Niall Brennan, MPP, Kimberly A. Lochner, ScD, and
Patrick Conway, MD, MSc, Centers for Medicare &
Medicaid Services, US Department of Health and
Human Services, who provided feedback on an
earlier version of the manuscript. None of these
individuals was compensated for contributions to
this article.
REFERENCES
1. Parekh AK, Barton MB. The challenge of multiple
comorbidity for the US health care system. JAMA.
2010;303(13):1303-1304.
2. Tinetti ME, Fried TR, Boyd CM. Designing health
care for the most common chronic
condition—multimorbidity. JAMA. 2012;307(23):
2493-2494.
3. Ward BW, Schiller JS. Prevalence of multiple
chronic conditions among US adults: estimates
from the National Health Interview Survey, 2010.
Prev Chronic Dis. 2013;10:65.
4. Lochner KA, Cox CS. Prevalence of multiple
chronic conditions among Medicare beneficiaries,
United States, 2010. Prev Chronic Dis. 2013;10:61.
5. Parekh AK, Goodman RA, Gordon C, Koh HK;
HHS Interagency Workgroup on Multiple Chronic
Conditions. Managing multiple chronic conditions:
a strategic framework for improving health
outcomes and quality of life. Public Health Rep.
2011;126(4):460-471.
6. Blumenthal D. Performance improvement in
health care—seizing the moment. N Engl J Med.
2012;366(21):1953-1955.
7. Schwenk TL. The patient-centered medical
home: one size does not fit all. JAMA. 2014;311(8):
802-803.
Box. Vision and Goals of the US Health and Human Services’
Strategic Framework on Multiple Chronic Conditions
Goal 1: Foster Health Systems Change
Identify evidence-supported models to improve care coordination
Define appropriate health care outcomes
Develop payment reform and incentives
Implement and effectively use health information technology
Prevent the occurrence of new chronic conditions
Perform purposeful evaluation of models of care
Goal 2: Empower Individuals
Facilitate self-care management
Facilitate home and community-based services
Provide tools for medication management
Goal 3: Equip Clinicians
Identify best practices and tools
Enhance health professionals’ training
Address multiple chronic conditions in clinical practice guidelines
Goal 4: Enhance Research
Increase the external validity of trials
Understand the epidemiology
Increase patient-centered health research
Address disparities
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