Chronic disease and illness care

Nature of conditions

While the terms chronic disease and chronic illness are often used interchangeably in the clinical literature and in health services policy and organization, they convey different meanings that require clarification (Table 14–6). Chronic disease is defined on the basis of the biomedical disease classification, and includes diabetes, asthma, and depression.4 Chronic illness is the personal experience of living with the affliction that often accompanies chronic disease. It is often not recognized in health systems, because it does not fit into a biomedical or administrative classification.6 Family medicine principles champion the patient-centred care of chronic illness.5

Chronic disease and illness occur in complex interdependencies and continue across the lifespan. They are greatly influenced by socioeconomic status, education, employment, and environment.2 Thus, unless the underlying determinants of health, well-being, and the community context are addressed through a continuum of health promotion and empowerment from wellness to disease and illness care, the least advantaged will experience widening disparities in outcomes.2

Chronic care model

The chronic care model (CCM) describes chronic care as “the prevention and diagnosis, management, and palliation of chronic disease” and is internationally accepted as the main strategic response to the challenges of chronic disease.7 The model calls for the redesign of health care to provide continuous, coordinated multi-faceted systems of health service delivery.3 The CCM is based on a Cochrane systematic review of chronic care interventions.7 For example, key elements of the CCM, as identified in the research literature,8 include the following:

• personnel and care processes to support proactive care, including planned care and care coordination, and scheduling or coordination of visits and follow-up;

• decision support for providers, including disease management guidelines and protocols;

• information systems to ensure access to timely and relevant information;

• support for patient empowerment and self-management;

• community resources to inform and support patients; and

• system support for chronic illness care among providers integrated into care networks.

A synthesis of randomized controlled trials and controlled before-after studies of various components supports the CCM, although there have been no published trials evaluating the full effect of the comprehensive model, and there have been mixed results related to how to implement adapted components.9 Nonetheless, this CCM is being adapted and adopted by most provinces in Canada. Earlier adopters have been British Columbia and Alberta, spreading from west to east from Group Health Seattle and the Wagner group. Local adaptation and adoption of the CCM are endorsed by the World Health Organization. These models promote proactive patients, communities, and providers; integrated and coordinated care, which includes office systems that support adherence to disease management guidelines and the promotion of structured and planned care; teamwork; care coordination; and self-management support (Table 27).

Variations of care strategies

Currently, as local variations of the CCM are being implemented, there are intense activities afoot to integrate family medicine—a medical discipline—into comprehensive primary care (PC) and primary health care (PHC) models.

A medical care model is the term for the set of procedures in which all doctors are trained in Western medicine. This set includes complaint, history, examination, ancillary tests if needed, diagnosis, treatment, and prognosis with and without treatment, based on a biomedical classification system.4

Primary health care incorporates personal care with health promotion, the prevention of illness, and community development. The philosophy of PHC includes the interconnecting principles of equity, access, empowerment, community self-determination, and intersectoral collaboration. It encompasses an understanding of the social, economic, cultural, and political determinants of health.10

Primary care is more clinically focused and can be considered a subcomponent of the broader PHC system.11 Until recently, PC was considered health care provided by a medical professional that is a client’s first point of entry into the health system. Primary care in Canada is increasingly multidisciplinary, with nurses and allied health and other community providers working in teams with family physicians.

The new orientations for PHC set out in the 2005 Declaration of Montevideo,12 to which Canada is a signatory, are predominantly a response to the challenge of burgeoning communicable and non-communicable chronic disease with health services that remain attuned to acute care paradigms.13 Table 3 illustrates the evolving health system models in which family medicine is or will be operating to provide future chronic disease and illness care in Canada, starting from the basis of the biomedical disease model of a medical speciality.14

Principles of family medicine

Framework for chronic care

The principles of family medicine address both chronic disease and illness, with longitudinal care that is patient-centred, relationship-based, integrated, and community oriented (Table 4). Thus, these principles are synergistic with the CCM, although it places less emphasis on the role of the FP and the doctor-patient relationship. As PC and PHC are implemented as multidisciplinary and population-based systems, respectively, the substantial system redesign aligns both with the CCM and with the family medicine principles. However, as the multiplicity of approaches has the potential to create confusion and frustration, an explicit coherent chronic care framework is needed to adapt to the way family medicine works. Such a framework is needed to model the pathways through health, disease, and illness in the life course of those afflicted, and the family medicine roles across the phases of prevention, treatment, and care. Without such a framework on which to build evidence, there are hidden threats as well as opportunities.

Comparison of the roles of the principles of family medicine in relation to the health system models in which family medicine operates—the chronic care, medical care, PC, and PHC models—described in Table 2 and Table 4, identified gaps and synergies. In particular, illness and healing through a long-term personal patient-physician relationship can increasingly be overlooked in an overly disease-orientated or population-focused emphasis. None of the models or systems are discrete and all are constantly changing and adapting and adopting each others’ ideas. The 2 elements that emerge as “missing” from the 4 principles of family medicine are the centrality of the patient journey, including an emphasis on self-management support with an activated community, and the emerging role of family medicine in multiple health system models and ongoing system change.

Additional principles

Given current policy imperatives, it is important that family medicine advocates for patient-centred care and takes a leadership role in system redesign implementation. I propose the following 2 principles to enhance the existing 4 principles of family medicine as a framework for system redesign to address the burden of burgeoning chronic disease.