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Goal: Affinity is
seeking projects that aim to improve how care is
delivered for those suffering with multiple chronic
conditions. Projects should focus on improving
care-coordination processes, simplifying and improving
how multiple conditions are managed, and reducing the
burden of illness.
Overview: Nearly one-quarter of Americans have
two or more co-existing diseases, and face numerous
health risks and limitations. Coordination of care for
people with multiple conditions is lacking and many
patients report difficulties in getting the care they
need from their providers. Changing how health care is
delivered, especially to these patients, is imperative.
Additionally, patients must become partners with the
care delivery system to better understand and manage
their illnesses, prevention strategies, treatment
regimens, and physician appointments. Informed patients
taking a more active part in their care and providers
with resources and expertise in chronic disease
management will lead to a major improvement in the
health care system.
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In adults, leading chronic conditions include
hypertension, heart and respiratory diseases, arthritis,
and mental health disorders. Leading chronic conditions
in children include asthma and other respiratory
diseases, obesity, and emotional / behavioral disorders.
Nationwide, five percent of children have more than one
chronic disease. Two-thirds of the population aged 65
and over today have two or more chronic conditions.
Economically-deprived and minority populations have
greater treatment needs than others. In New York City,
nearly half of high-cost Medicaid patients ages 18 to 64
have multiple chronic diseases. As in other areas of
healthcare, disparities exist in the treatment of
persons with multiple chronic conditions. Hispanics and
non-whites with serious chronic conditions report higher
levels of unmet service needs compared to white
non-Hispanics with these diseases.
People with chronic diseases use medical services at
higher rates, and often receive duplicate testing,
conflicting treatment advice and prescriptions that are
contra-indicated. Inappropriate hospitalizations
increase as the number of chronic conditions increase.
This is partially attributable to poor care coordination
and other difficulties within the health system. Often,
caring for those with multiple chronic conditions is
left to the family who assume the responsibility of
helping coordinate and provide both medical and
non-medical care.
Solutions must recognize better care coordination as a
major factor in improving health outcomes for those with
multiple chronic conditions. Initiatives must recognize
treating the person as a whole -- not just treating
single conditions. The Center for Health Care
Strategies’ national collaborative is developing and
testing models of care delivery for Medicaid consumers
with multiple diseases. Interventions include: improving
identification and surveillance of multiple conditions,
monitoring and management of medication, integrated
multidisciplinary care teams, health navigators,
implementing information systems and registries to track
and better monitor patients, clinician training, patient
education, and care delivery outside of provider
offices. Improving care delivery will ultimately result
in informed patients taking an active part in their
healthcare, and providers with resources and expertise
in chronic disease care management.
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