Chronic Disease Management (eBook)

Preface 5
Contents 7
Contributors 9
Section I Background 11
1 Overview of Chronic Disease Management 12
Reference 17
2 Self-Management in Chronic Illness 18
Summary 18
Introduction 21
Self-Management/Empowerment Overview 23
Background 23
Team Approach with the Patient as Captain 23
Behavior Change/Transtheoretical Model 25
Motivational Interviewing 26
Agenda Setting 27
Importance/Confidence Ruler 29
Typical Day Strategy 29
Hypothetical Look over the Fence 30
Exploring Pros and Cons of Changing or Not Changing 30
Appropriate Information Exchange 31
Assessment Tools 31
Cascade of Successes 34
Patient-Centered Care 34
Shared Medical Appointments 34
Goal Setting 35
Action Plans 36
Self-Management Education and Training Programs 37
Self-Monitoring, Data Management, and Use of Registries 38
Summary 39
References 39
3 Use of Group Visits in the Treatment of the Chronically Ill 41
Summary 41
Introduction 45
Group Visits Address Psychosocial and Medical Needs of the Chronically Ill 47
Three Current Major Group Visit Models 48
The DIGMA Model 48
Triple Productivity 49
DIGMAs Have Unique Features 49
Efficiency Is Gained in Two Ways 51
The Issue of Billing 52
Strengths 52
DIGMAs Have Widespread Applications 54
Patients 54
For DIGMAs to Succeed, the Physician Must Take Primary Responsibility for Inviting Patients 56
How Physicians Should Invite Patients 57
Staffing 58
The Behaviorist’s Responsibilities 58
How Documentation Is Handled 59
Larger Systems Need a DIGMA Champion, a Program Coordinator, and Dedicated Schedulers 61
Subtypes of the DIGMA Model 62
The Homogeneous Subtype 62
The Heterogeneous Subtype 63
The Mixed Subtype 64
Flow 65
With DIGMAs, Conduct as Much as Possible in the Group Setting 66
Few, if Any, Patients Will Need to Be Seen Outside of the Group 66
Weaknesses 67
Patients are Often More Open in the Group Setting 68
Although Counterintuitive, the Heterogeneous Model Is Often Best 68
Most Physician Fears Quickly Fade, but Ideal Group Size Remains an Ongoing Issue 68
Experience with Other Types of Groups Does Not Necessarily Make for a Good DIGMA 69
DIGMA Requirements 69
Facilities 69
Personnel 70
Promotional Materials 70
Chronic Illness Outcomes Studies Are More Difficult with DIGMAs Than with CHCCs 71
Keeping Sessions Filled When No Access Problems Exist 71
DIGMAs Can Exacerbate Preexisting Systems Problems 72
DIGMAs Represent a Major Paradigm Shift 72
The CHCC Model 73
Strengths 73
Patients 74
Staffing 74
Structure 75
Subtypes 76
Flow 77
Warm-Up 77
Educational Presentation 77
Working Break and Delivery of Medical Care 77
Questions and Answers 78
Planning for the Next Session 78
Individual Visits 78
Weaknesses 78
Practice Management Limitations 79
Limits for Chronic Illness Program Applications 79
Other Difficulties 79
The Physicals SMA Model 80
Hallmarks of the Physicals SMA Model 81
Subtypes 82
Respecting Patient Privacy in the Physicals SMA Model 83
Facilities 83
Overbook Sessions to Avoid Costly Down Time 84
Three Basic Components of Physicals SMAs 84
The Initial Patient Packet 84
The Physical Examination 85
The Interactive Group 85
Census Targets for Physicals SMAs 85
Strengths 86
Physicals SMAs Can Be Employed in a Wide Variety of Chronic Illness Programs 86
Staffing 86
Conduct Physical Examinations First, Before the Group 88
Conduct Your Group Visit Program by Sticking Closely to the Established Models 89
Subtypes 89
Billing 90
Weaknesses 91
The Logistics of Handling the Patient Packet Must Be Addressed 92
Final Comments on DIGMAs, CHCCs, and Physicals SMAs 93
DIGMAs Are Particularly Well Suited to Chronic Illness Treatment Programs 93
Which SMA Model Should You Start With? 93
Summary 94
References 95
4 Chronic Disease Care: Creating Practice Change 96
Change is Difficult: Summary 96
Background 97
Build a Team 97
Start with a Champion 98
Starting the Process 98
Start with a Patient Story 99
Designate Time: Consider Using a “Huddle” 100
Tools for Helping Clinical Systems Change 101
What Are You Trying to Accomplish? 103
How Will You Know That a Change Is an Improvement? 103
What Changes Can You Make That Will Result in Improvement? 105
A Tool for Testing Changes: The PDSA Cycle 106
Plan 108
Do 108
Study 109
Act 109
Linking Your Cycles 110
Summary: Lessons Learned 110
References 112
5 Medication Management in Chronic Diseases 113
Summary 113
Polypharmacy 114
Summary 114
Background 114
Costs 115
Epidemiology 115
Management 116
The Elderly Population 118
Medication Errors 121
Summary 121
Background 121
Discussion 122
Cost Containment 123
Summary 123
Background 123
Conclusion 128
References 130
6 Providing Culturally Competent Chronic Disease Management: Diabetes Mellitus 132
Summary 132
Background 133
Cultural Challenges 133
Methods to Enhance Cross-Cultural Understanding 134
Keep Lines of Communication Open 134
Acknowledge Differences in Beliefs 135
Foster Self-Management 135
Diminish Literacy Barriers 135
Use Community Leaders and Peer Counselors 136
Diabetes: General Education 136
Cultural Framing 136
Attitudes and Behaviors Regarding Diabetes Among Specific Cultural Groups 137
Summary 143
References 144
Section II Management of Specific Diseases 146
7 Type 2 Diabetes 147
Summary 147
Background: Burden as a Chronic Disease 152
Summary 152
Prevalence 152
Costs 153
Impact of Disease Management Programs 153
Summary 153
Screening for Diabetes 155
Summary 155
Risk Factors 156
Impact of the Obesity Epidemic 156
Screening Populations for DM 156
Screening Tests 157
Impaired Fasting Glucose Condition (Pre-diabetes) 158
Screening Recommendations 158
Initial Evaluation 159
Summary 159
Assessments 159
Management 161
Summary 161
Self-Management Support and Assessing Readiness to Change 162
Self-Management Support and Training for Patients 163
Self-Management Support/Promotion by Providers 164
Developing a Short-Term Action Plan 164
Helping Patients Set Their Goals 164
Motivational Interviewing 165
Education Supporting Self-Management 166
Monitoring Blood Glucose Level 166
Nutrition Therapy 167
Carbohydrate Counting 168
Reduction in Fat 169
Weight Control 170
Exercise 170
Foot Care 170
Behavioral Concerns 171
Education Resources 171
Medications 172
Summary 172
Starting a Medication Regimen 175
Cost Considerations 175
Areas of Caution 175
Weight Gain and Sulfonylureas 175
Metformin and Lactic Acidosis 175
Thiazolidinediones and Heart Failure 175
Thiazolidinediones and Hepatotoxicity 176
Glipizide and Hypoglycemia in the Elderly 176
Triple-Drug Regimens 176
Alpha-Glucosidase Inhibitors and Hypoglycemia 176
Insulin 176
Monitoring 178
Summary 178
Documentation 179
Quality of Care 179
Methods to Improve Outcomes 185
Alternative Therapy 187
Summary 187
Summary 192
References 193
Appendix A Diabetes Self-Management: Setting Goals 196
Appendix B Nutrition and Type 2 Diabetes 197
HEALTHFUL EATING 197
GENERAL NUTRITION GUIDELINES 197
SERVING SIZES/PORTIONS 198
TIMING OF MEALS 198
ALCOHOL 198
CALORIE-FREE SWEETENERS 198
FIBER 199
SODIUM 199
USE LESS FAT IN COOKING 203
ADD LITTLE OR NO FAT TO FOODS 203
STAY AWAY FROM “FAST FOODS” 203
WATCH OUT FOR THESE FOODS THAT ARE HIGH IN FAT: 203
USE “FREE FOODS” 204
READ LABELS FOR FAT CONTENT 204
DIABETES RESOURCE LIST 205
Appendix C Exercise: Getting Started 207
Appendix D Taking Care of Your Feet in Diabetes: Patient Education Sheet for UC Davis Health System 208
What You Should DO to Take Care of Your Feet 208
DO NOT DO THE FOLLOWING TO YOUR FEET 209
8 Asthma 210
Summary 210
Management 210
Monitoring 212
Background 214
Summary 214
Prevalence and Impact on Society 214
Cost of Asthma Health Care 215
Chronic Disease Management Programs 216
Summary 216
Recent Studies 216
University of California, Davis Asthma Network 218
Evaluation of Asthma: Initial and Subsequent 221
Summary 221
Diagnosis 221
Quality of Life Assessment 227
Management 229
Summary 229
Asthma Control 230
Assessing Importance 237
Management Key Points 239
Assessing Self-Efficacy and Confidence 242
Barriers to Self-Management 242
Fast Facts 242
Overcoming Barriers 243
Role for Respiratory Therapists 244
Difficult-to-Control Asthma 246
Clinical Performance Measures 248
Asthma Assessment 252
Pharmacologic Therapy 252
Plan-Do-Study-Act 252
Alternative Therapies 253
References 254
9 Heart Failure 256
Summary 256
Management 256
Monitoring 258
Burden as a Chronic Disease 259
Fast Facts 259
Background 259
Prevalence 260
Costs 261
Impact of Disease Management Programs 261
Summary 261
Background 262
Screening for Heart Failure 264
Summary 264
Documenting Heart Failure 265
Screening for Heart Failure 268
Detection of Left Ventricular Hypertrophy 268
Electrocardiogram 268
Two-Dimensional Echocardiogram 269
Brain Natriuretic Peptides 269
Initial Evaluation 270
Summary 270
Patients at High Risk for Developing Heart Failure: “Pre-Heart Failure” 271
Patients Identified with Heart Failure 273
Impact on Quality of Life 275
Classifying the Severity of Heart Failure 275
Other Methods of Assessing Function: The Six-Minute Walk Test 278
Ongoing Evaluation 279
Management 279
Fast Facts 279
Management of High-Risk Patients 281
Self-Management Support and Assessing Readiness to Change 282
Studies on the Effectiveness of Self-Management Support 283
Predictors of Self-Care 283
Methods of Promoting Self-Management 283
Use of a Pharmacy-Based Support Intervention 283
Web-Based Communication 283
Peer Support 284
Home Health Intervention 285
Patient Training 285
Barriers to Self-Care 285
Provider Support for Self-Management 289
Developing a Short-Term Action Plan 289
Helping Patients Set Their Goals 289
Education to Support Self-Management 290
Monitoring Symptoms 290
Nutrition Therapy 290
Exercise 291
Behavioral Concerns 292
Education Resources 292
Medications 293
Summary 293
Angiotensin-Converting Enzyme Inhibitors 295
Angiotensin Receptor Blockers 297
Beta-Blockers 298
Starting Beta-Blockers 299
Management of Worsening Heart Failure During Beta-Blockade 300
Aldosterone Antagonists 300
Digoxin 301
Isosorbide Dinitrate and Hydralazine 302
Cost-Effective Considerations 302
Monitoring 303
Summary 303
Background 303
Documentation 304
Measures to Improve Quality of Care 304
Alternative Therapies 309
Summary 309
Usage 310
Summary 310
References 311
10 Osteoarthritis 315
Chapter Summary 315
Management 315
Burden as a Chronic Disease: Summary 317
Introduction 322
Initial Evaluation 324
Systemic Analgesics 325
Acetaminophen 326
Nonsteroidal Anti-Inflammatory Drugs 326
Other Analgesics 327
Glucosamine 328
Intra-Articular Injections 328
Hyaluronan 329
Exercise 329
Assistive Devices and Joint Protection 330
Surgical Treatment 331
Self-Management Support 331
References 332
11 Obesity 335
Background: Burden as a Chronic Disease 335
Costs 335
Impact of Disease Management Programs 335
Initial Evaluation 336
Management 337
Medications 338
Monitoring 339
Alternative Therapy 340
Summary 340
References 340
12 Depression 341
Background: Burden as a Chronic Disease 341
Costs 341
Impact of Disease Management Programs 342
Initial Evaluation 343
Management 345
Treatment Options: Psychotherapy and Medications 345
Psychotherapy 345
Antidepressant Medications 345
Depression Disease Management Program 348
Monitoring 350
Alternative Therapy 351
Summary 352
References 352
13 Chronic Pain 354
Background: Burden as a Chronic Disease 354
Costs 354
Impact of Disease Management Programs 354
Initial Evaluation 355
Management 356
Medications 356
Opioids 358
Other Drugs 359
Comorbid Conditions 359
Self-Management Support 359
Patient Education 360
Referral to a Pain Specialist 361
Monitoring 361
Documenting Pain Severity 361
Comorbid Conditions 362
Developing a Pain Contract 363
Compliance with State and Federal Regulatory Boards 364
Alternative Therapies 364
Summary 364
References 365
Index 367

"5 Medication Management in Chronic Diseases (p. 104-105)

Timothy W. Cutler and Marilyn Stebbins

Summary

Over the past two decades a signi? cant portion of the biotechnological advances in health care has involved pharmaceuticals. With the combination of the use of novel medications for new and existing indications, and the increasing number of new indications for older medications, prescription drug use and costs continue to be among the fastest growing segments of health care. In fact, over the past decade the Food and Drug Administration (FDA) has increased substantially the number of new drug approvals and has created a fast-track system for pharmaceutical manufacturers to expedite the approval process.

This, however, has not come without a price tag from both the ? nancial and utilization perspectives. Financially, there have been double-digit increases in pharmaceutical expenditures, while at the same time prescription drug coverage for individuals appears to be shrinking, thus increasing out-of-pocket expenditures.

From the utilization perspective, with more drugs available and more indications for drugs, there has been an increase in polypharmacy, which can place the patient at risk for adverse drug reactions, drug interactions, and medication errors. With the passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA 2003), Medicare will be offering an outpatient prescription drug bene? t for the ? rst time in its 40-year history beginning in 2006. Although older Americans comprise 15 percent of the population, they account for about 40 percent of the drug expenditures [1].

Because of such statistics the new Medicare drug bene? t is intended not only to improve access to medication therapy but also to ensure that medications are used safely and effectively [2]. This chapter includes information on polypharmacy, medication errors, and cost containment, as well as strategies for primary care providers to incorporate into their management of chronic diseases.

Polypharmacy

Summary
• Polypharmacy may be present when prescription or over-the-counter (OTC) medications are duplicating the therapeutics of other prescription medications.
• Polypharmacy and nonadherence to medications increase morbidity and mortality.
• Polypharmacy has a negative ? nancial impact on the cost of health care and increases patient out-of-pocket spending.
• Nonadherence is closely linked to the number of medications a patient takes.
• Patients taking ? ve or more medications are at twice the risk for developing medication-related adverse events than those who take fewer medications.
• Complete medication histories are crucial to identifying polypharmacy.
• The elderly are at particular risk for polypharmacy."