Facing chronic diseases

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

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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, although getting support from health services as Inspire community also help with these challenges.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