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Improving chronic care medication adherence via collaborative models

  • Chronic illnesses are prevalent, costly, and significant contributors to death and disability; addressing chronic conditions and their drivers might help reduce disease progression and improve well-being during the life course1.
  • The Chronic Care Model (CCM) is a framework being used in United States primary care settings for delivering specialized care to people with chronic illnesses2.
  • Leveraging technological improvements, such as mobile health applications and remote monitoring devices, provides another layer of efficacy by enabling real-time communication, personalized therapies, and data-driven insights3.

Understanding medication non-adherence in chronic conditions

According to World Health Organization (WHO), chronic condition tend to last longer and are the result of a combination of genetic, physiological, environmental, and behavioral factors4. Some of the examples are a depressive disorder; coronary heart disease; chronic obstructive pulmonary disease; diabetes; and high blood pressure1. The long-term nature of these diseases puts a strain on finances5. Medication non-adherence is a widespread challenge in managing chronic illnesses5. It is attributed to several factors such as socioeconomic, healthcare system-related, patient-related, disease-related, and therapy-related6. To know more about these factors/barriers driving nonadherence please read our previous article: Overcoming barriers to medication adherence: a comprehensive guide.

Lately, the focus of healthcare services has shifted from disease management to patient-centered care. Nevertheless, implementing these changes seem difficult due to limited resources. One way to improve chronic disease management using a patient-centered approach is Chronic Care Model (CCM)7.

What is the Chronic Care Model (CCM)?

The CCM is a framework for delivering specialized care to people with chronic diseases. According to a Centers for Disease Control and Prevention (CDC) publication, the CCM is a systematic approach to restructuring medical care designed to create a partnership between the health system and the communities they serve2. It was established from the outset as a multicomponent care organization, based on evidence that targeting single-care procedures does not improve outcomes for chronic diseases8.

Key components of CCM in healthcare

CCM consists of six components anticipated to impact functional and clinical outcomes linked with managing diseases9. These components are:

  • Health care organization: An organization or institution that promotes efficient, secure, constant, and high-quality care, emphasizes improvement initiatives, and helps patients to move among all levels of the health system and between multiple providers, as needed.
  • Service delivery design: To improve clinical care delivery and promote patient self-management, healthcare practitioners should be assigned responsibilities and activities that allow for culturally acceptable interactions.
  • Decision support: Guidance for implementing evidence-based care to encourage patient participation.
  • Clinical information systems: Tracking progress through reporting outcomes to patients and providers to generate timely reminders for patients and providers to reinforce adherence with improvement protocols and strategies.
  • Support for self-management: Empower and prepare patients to play a central role in their health by using different strategies to support patient self-management, including evaluation, goals, plan of action, problem-solving, and monitoring.
  • Community support: Sustaining care by using community-based resources and public health policy. The health care organization may build relationships with community organizations to cover service gaps and push for improved health care services.

Ultimately, the CCM model using various approaches encourages a productive engagement between a well-informed patient and a well-prepared health staff, resulting in better health outcomes.

Different models/approaches to improve Chronic care

Chronic care can be improved using different approaches such as9,10:

  • Breakthrough series: A collaborative methodology
  • Team-based care
  • Integrated approach

  • Breakthrough series: A collaborative methodology
    The Breakthrough Series (BTS) is a quality improvement model, developed by the Institute for Healthcare Improvement (IHI) to improve chronic disease care. A Breakthrough Series Collaborative is a short-term (6 – 15 months) learning system, which involves successive Plan, Do, Study, Act (PDSA) cycles accompanied by periodic measurements to determine the effects of the changes and whether they represent an improvement. One such project that uses BTS and chronic care model to improve the quality of diabetes care was VIDA Project (Veracruz Initiative for Diabetes Awareness) for quality improvement. In a comparative study, the percentage of people with good blood sugar control (A1c<7%) improved from 28% prior to the intervention to 39% post intervention9.

  • Team-based care in chronic disease
    Team-based care is a strategy implemented at the health system level. The strategy aims to enhance patient care by having HCPs from different disciplines who work collaboratively with the patient and their primary care provider (PCP). The team includes the patient and the patient’s PCP, as well as other clinical HCPs. These members use their unique training and skills to implement team-based care11. One such program that uses team-based care for improving blood pressure control is Buchanan Cares, which was developed in Buchanan country, Virginia. This program was designed to reduce patient readmission and improve patient outcomes. The initiative involved student and community pharmacists collaborating with the attending physician to address medication-related queries, involve patients in their care, conduct medication reviews, and provide education while patients were hospitalized. After discharge, patients were followed up by pharmacists for a period of 30 days. During this time, they conducted medication reviews, monitored health status, assessed satisfaction, and communicated with primary care physicians regarding medication-related matters, concerns, and readmissions were tracked. The Buchanan Cares program received positive feedback from both patients and HCP during the transition from hospital to home as none of the patients who completed the program were readmitted within 30 days, underscoring its effectiveness in preventing readmissions11.

  • Integrated approaches to chronic care management
    Integrated healthcare embodies a collaborative and communicative approach among healthcare professionals12. When treating chronic illness, how often does HCP consider a patient’s mental health? The two may appear unrelated, however, data have shown a strong link between them13. For instance, Depression is commonly seen in patients with diabetes, and other chronic diseases. Evidence supports integrated approach addressing both the physical and psychological aspect in reducing distress and improving glycemic control. A pilot study invited patients treated at a public diabetes center to participate in a treatment program that included group psychotherapy sessions in addition to the standard biomedical treatment and compared with a second group of patients from the same center. Standard treatment (ST) was performed and integrated treatment (IT) was added with group psychotherapeutic intervention with ST to promote emotional, cognitive, or behavioral changes that support people in changing their lifestyle and improving their chronic condition. The result demonstrated reduction in blood lipids and triglycerides, chronic depressive and anxious mood states, patient emotional coping, and the number of specialist visits and diagnostic tests14.

In addition to these approaches, technological innovations such as telehealth and remote patient monitoring (RPM) can be seen to play a significant role in managing chronic condition, track their progress, and make informed decisions about patient well-being15.

The power of integrating CCM and Remote Patient Monitoring (RPM)

By implementing CCM and Remote Patient Monitoring (RPM) in tandem, a powerful combination of physician practices and health systems can be unlocked. Telehealth is the remote delivery of health care using a range of telecommunication methods. Although not a specific component of the CCM, telehealth may aid in consultation with specialized teams as part of a shared care framework16. To know more about telehealth improving medication adherence please read: Telemedicine revolutionizing healthcare: A key to the future of medication adherence.
The various tools of telehealth that support chronic care at home includes15:

  • Virtual visit: Patient-clinician connections remotely can facilitate symptom management, medication review, exercise, nutrition, and overall patient care.
  • Assess symptoms: To determine the correct course of action, symptoms can be assessed frequently that provide real-time insight into the patient care.
  • Medication reminders: Helps timely intake of medication, correct dose, and building habit towards medication regimen, leading to lasting behavior changes and improved outcomes.
  • Condition specific education: Improve health literacy and overall engagement by providing educational materials.

CCM model induces active participation in patients, and they can have valuable information at their fingertips, which helps them have more meaningful conversations with their HCPs, leading to enhanced disease management.

Case studies: successful Chronic Care Models in action.

The chronic care model has come into action, and its efficacy in improving outcome of chronic disease has been reported in several studies.

  • Improving outcomes in chronic illness via team-based care
    A meta-analysis investigating team intervention (e.g. coordination, collaboration, interaction, involvement of different team members, role sharing, shared decision-making, or leadership) in primary care and its relationship with patient outcomes in chronic diseases. The study reported, team-based intervention demonstrated a reduction in mean systolic blood pressure (MD = 5.88, 95% CI 3.29–8.46, P= <0.001, I2 = 95%), diastolic blood pressure (MD = 3.23, 95% CI 1.53 to 4.92, P = <0.001, I2 = 94%), and HbA1C (MD = 0.38, 95% CI 0.21 to 0.54, P = <0.001, I2 = 58%)17.

  • Improving outcome in diabetes via Chronic Care Model
    A meta-analysis using 17 studies from January 1990 to June 2021 revealed, CCM interventions significantly decreased HbA1c levels compared to usual care, with a mean difference (MD) of −0.21%, 95% CI −0.30, −0.13; Z = 5.07, p<0.0000118.

  • Improving outcome in chronic heart failure patients via collaborative care
    Despite multiple palliative care requirements in heart failure, the patients are generally not examined by experts due to their limited availability. Collaborative care intervention (CCI) was developed to overcome this challenge by providing intervention with multidisciplinary teams. Cui X., et al. 2019 in a meta-analysis included 21 studies reported significantly improved quality of life in the CCI group compared with the routine care group (SMD=0.60, 95%CI 0.27–0.94, Pheterogeneity<.001, I2=94.1%)19. 

Conclusion

Collaborative models offer promising avenues for enhancing medication adherence among individuals with chronic illnesses. Using collaborative chronic care model – which emphasizes team-based care, patient education, and proactive outreach – healthcare providers can address the multifaceted challenges of medication adherence. Integrated care approaches further bolster these efforts by ensuring seamless coordination between healthcare professionals and empowering patients with comprehensive support systems. Leveraging technological advancements, such as mobile health applications and remote monitoring devices, adds another layer of efficacy by facilitating real-time communication, personalized interventions, and data-driven insights. By embracing these strategies synergistically, healthcare systems can significantly enhance medication adherence and ultimately improve the quality of life for those living with chronic conditions.

“Never let the things you cannot do prevent you from doing the things you can.”
— John Wooden.”

References

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  2. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in us primary care settings: A systematic review. Prev Chronic Dis. 2013;10(2). doi:10.5888/pcd10.120180
  3. O’Hara D V., Yi TW, Lee VW, Jardine M, Dawson J. Digital health technologies to support medication adherence in chronic kidney disease. Nephrology. 2022;27(12):917-924. doi:10.1111/nep.14113
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