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Optimizing Health for Persons With Multiple Chronic Conditions FREE ONLINE FIRST

Anand K. Parekh, MD, MPH1; Richard Kronick, PhD2; Marilyn Tavenner, RN, MHA3
[+] Author Affiliations
1Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC
2Agency for Healthcare Research & Quality, US Department of Health and Human Services, Washington, DC
3Centers for Medicare & Medicaid Services, US Department of Health and Human Services, Washington, DC
JAMA. Published online August 18, 2014. doi:10.1001/jama.2014.10181
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Published online

The challenges for the US health care system of high health care costs and poor health outcomes in individuals with multiple (2 or more) concurrent, chronic conditions have been well documented.1,2 Estimates are that more than one-quarter of all adults have multiple chronic conditions3; in addition, more than two-thirds of Medicare fee-for-service beneficiaries have multiple chronic conditions, with 14% having 6 or more common conditions.4 Recently, the Centers for Medicare & Medicaid Services (CMS) released new data resources on chronic conditions among Medicare fee-for-service beneficiaries to better define the burden of chronic conditions among beneficiaries and the implications for the US health care system.

In response to this public health challenge, the US Department of Health and Human Services (HHS) released its report “Strategic Framework on Multiple Chronic Conditions” in 2010. The strategic framework, developed with private sector input, provides HHS and its partners with a roadmap for improving the health status of persons with multiple chronic conditions across 4 overarching goals5 (Box). Within the first few years of implementation, the strategic framework has led to the following selected actions and continues to offer additional opportunities for further collaboration.

Box Section Ref ID

Box.
Vision and Goals of the US Health and Human Services’ Strategic Framework on Multiple Chronic Conditions
Goal 1: Foster Health Systems Change
  • Identify evidence-supported models to improve care coordination

  • Define appropriate health care outcomes

  • Develop payment reform and incentives

  • Implement and effectively use health information technology

  • Prevent the occurrence of new chronic conditions

  • Perform purposeful evaluation of models of care

Goal 2: Empower Individuals
  • Facilitate self-care management

  • Facilitate home and community-based services

  • Provide tools for medication management

Goal 3: Equip Clinicians
  • Identify best practices and tools

  • Enhance health professionals’ training

  • Address multiple chronic conditions in clinical practice guidelines

Goal 4: Enhance Research
  • Increase the external validity of trials

  • Understand the epidemiology

  • Increase patient-centered health research

  • Address disparities

GOAL 1: FOSTER HEALTH SYSTEMS CHANGE

New Models of Care

The Affordable Care Act has accelerated efforts to coordinate and manage care for individuals with multiple chronic conditions through broad-based models such as accountable care organizations and patient-centered medical homes. In addition, specific models focused on the multiple chronic conditions population are also being tested by CMS, such as the Independence at Home demonstration, which is providing home-based primary care to 8000 frail Medicare beneficiaries with multiple chronic conditions and functional limitations. In addition, the Medicaid Health Home state plan option to coordinate the primary, acute, behavioral, and long-term care of individuals primarily with multiple chronic conditions, many of whom have a serious mental illness, has been adopted by 15 states and serves more than 1 million Medicaid beneficiaries at the time of this publication. Approximately 40 000 Medicare-Medicaid enrollees, a group traditionally with high prevalence rates of multiple chronic conditions, are currently enrolled in new integrated care models in 6 states.

Payment for Non–Face-to-Face Care Management Services

In its 2014 physician fee schedule final rule, CMS finalized regulations to start in 2015 to establish separate payments for managing the care of patients with multiple chronic conditions outside of a face-to-face visit. This decision recognizes the importance of care-management services for patients with multiple chronic conditions, particularly those most vulnerable to poor outcomes and high costs.

GOAL 2: EMPOWER INDIVIDUALS

Evidence-Based Self-management Programs

In 2010, the Administration on Aging awarded approximately $30 million in grants from American Recovery and Reinvestment Act funds to expand participation in Stanford University’s Chronic Disease Self-Management Program. To date, 185 000 older US residents, the vast majority with multiple chronic conditions, have participated in a chronic disease self-management program. These programs have been shown to improve symptoms, prevent exacerbations of illness, and decrease emergency department visits. In 2013, CMS issued a report to Congress mandated by the Affordable Care Act on evaluating community-based wellness and prevention programs such as chronic disease self-management programs for their effects on Medicare beneficiaries. Retrospective analyses suggest potential cost savings for certain physical activity, falls prevention, and self-management programs.

GOAL 3: EQUIP CLINICIANS

Clinical Practice Guidelines and Quality Measures

In 2012, the Institute of Medicine and HHS convened expert stakeholders to discuss integrating information on comorbidities in clinical practice guidelines for specific conditions. Since that time, a number of professional societies, including the American College of Cardiology, American Heart Association, and the American Society of Clinical Oncology, have published guidelines with comorbidity-specific information to assist physicians and other front-line clinicians in better understanding the complexity of their patient populations. In addition, in 2012, the National Quality Forum, with funding from HHS, released a multiple chronic conditions measurement framework to provide guidance to measure developers as they generate appropriate measures for clinicians treating individuals with multiple chronic conditions.

Education and Training

In 2013, the Office of the Assistant Secretary for Health, in conjunction with the Health Resources Services Administration, launched an interprofessional health care education and training initiative to inform undergraduate, graduate, and continuing education curricula on core competencies essential to caring for the multiple chronic conditions population. The resources developed are slated to be released by the end of 2014 and then disseminated to training programs by the Health Resources Services Administration.

GOAL 4: ENHANCE RESEARCH

External Validity of Clinical Trials

In 2013, after commissioning a white paper on the issue, the US Food and Drug Administration (FDA) announced a new internal policy to more closely examine populations included in clinical trials by sponsors of new drug applications to discourage unnecessary exclusions and to encourage the inclusion of individuals with comorbidities. The FDA stated that its goal is to ensure that products coming to market will be safe and effective for all members of the public, and clinical trials that reflect the real-world population are an important part of achieving this goal.

Patient-Centered Outcomes Research

In 2010, the Agency for Healthcare Research & Quality awarded approximately $20 million in grants from American Recovery and Reinvestment Act funds to increase research on the influence of comorbidities on the treatment and management of particular chronic conditions. As a result of this opportunity, the agency expanded its nationwide multiple chronic conditions research network to 45 grantees from which a body of research has emerged in areas including comanagement of commonly concurrent conditions, guidelines for preventive services, and medication management in patients with multiple chronic conditions. In addition, the National Institutes of Health has funded and announced 7 new funding opportunities since 2010 focused on the multiple chronic conditions population. One of the most important of these is part of its health care systems research collaboratory to fund demonstration projects for pragmatic clinical trials focused on management of multiple chronic conditions.

CRITICAL NEXT STEPS

Although HHS and its partners have made incremental progress in addressing chronic conditions through use of a multiple chronic conditions lens, there is an imperative to accelerate efforts across all of the goals.

First, more delivery and payment models will need to focus specifically on subsets of the multiple chronic conditions population that are at highest risk for poor outcomes and high costs.6,7 Models that are shown to be effective and efficient should be widely disseminated and implemented.

Second, evidence-based community prevention and wellness programs currently reaching hundreds of thousands of individuals should be expanded further through partnerships with health care entities to reach tens of millions of individuals with multiple chronic conditions.

Third, the multiple chronic conditions population needs to be an area of focus for research on patient-centered outcomes to inform the development of future clinical practice guidelines, best practices, and quality measures.

HHS will continue to release data on chronic conditions so health leaders and innovators can better identify specific populations and geographic areas in which more coordinated and comprehensive approaches to prevention and treatment can be delivered to persons with multiple chronic conditions. Progress in these areas will be critical to improve the health status of individuals with multiple chronic conditions and to move toward a more effective and sustainable health care system.

ARTICLE INFORMATION

Corresponding Author: Anand K. Parekh, MD, MPH, Office of the Assistant Secretary for Health, US Department of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201 (anand.parekh@hhs.gov).

Published Online: August 18, 2014. doi:10.1001/jama.2014.10181.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We acknowledge Howard K. Koh, MD, MPH, Office of the Assistant Secretary for Health, US Department of Health and Human Services; Richard A. Goodman, MD, MPH, Centers for Disease Control and Prevention, US Department of Health and Human Services; and Niall Brennan, MPP, Kimberly A. Lochner, ScD, and Patrick Conway, MD, MSc, Centers for Medicare & Medicaid Services, US Department of Health and Human Services, who provided feedback on an earlier version of the manuscript. None of these individuals was compensated for contributions to this article.

REFERENCES

Parekh  AK, Barton  MB.  The challenge of multiple comorbidity for the US health care system. JAMA. 2010;303(13):1303-1304.
PubMed   |  Link to Article
Tinetti  ME, Fried  TR, Boyd  CM.  Designing health care for the most common chronic condition—multimorbidity. JAMA. 2012;307(23):2493-2494.
PubMed   |  Link to Article
Ward  BW, Schiller  JS.  Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010. Prev Chronic Dis. 2013;10:E65.
PubMed   |  Link to Article
Lochner  KA, Cox  CS.  Prevalence of multiple chronic conditions among Medicare beneficiaries, United States, 2010. Prev Chronic Dis. 2013;10:E61.
PubMed   |  Link to Article
Parekh  AK, Goodman  RA, Gordon  C, Koh  HK; HHS Interagency Workgroup on Multiple Chronic Conditions.  Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep. 2011;126(4):460-471.
PubMed
Blumenthal  D.  Performance improvement in health care—seizing the moment. N Engl J Med. 2012;366(21):1953-1955.
PubMed   |  Link to Article
Schwenk  TL.  The patient-centered medical home: one size does not fit all. JAMA. 2014;311(8):802-803.
PubMed   |  Link to Article

Figures

Tables

References

Parekh  AK, Barton  MB.  The challenge of multiple comorbidity for the US health care system. JAMA. 2010;303(13):1303-1304.
PubMed   |  Link to Article
Tinetti  ME, Fried  TR, Boyd  CM.  Designing health care for the most common chronic condition—multimorbidity. JAMA. 2012;307(23):2493-2494.
PubMed   |  Link to Article
Ward  BW, Schiller  JS.  Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010. Prev Chronic Dis. 2013;10:E65.
PubMed   |  Link to Article
Lochner  KA, Cox  CS.  Prevalence of multiple chronic conditions among Medicare beneficiaries, United States, 2010. Prev Chronic Dis. 2013;10:E61.
PubMed   |  Link to Article
Parekh  AK, Goodman  RA, Gordon  C, Koh  HK; HHS Interagency Workgroup on Multiple Chronic Conditions.  Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep. 2011;126(4):460-471.
PubMed
Blumenthal  D.  Performance improvement in health care—seizing the moment. N Engl J Med. 2012;366(21):1953-1955.
PubMed   |  Link to Article
Schwenk  TL.  The patient-centered medical home: one size does not fit all. JAMA. 2014;311(8):802-803.
PubMed   |  Link to Article

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