Chronic disease management programs

There is strong evidence that chronic disease management (CDM) programs improve quality of life (Cochrane-Poot 2021, John 2020, Cochrane-Peytremann-Bridevaux 2015, Miller 2013b, Cochrane-Archer 2012, Drewes 2012) and health outcomes for a variety of chronic conditions (John 2020, Baptista 2016, Cochrane-Peytremann-Bridevaux 2015, CG-CVD 2015, Cochrane-Poot 2021, Stellefson 2013b, Cochrane-Archer 2012, Woltmann 2012, Drewes 2012, Pimouguet 2011, Si 2008, CG-Diabetes), including mental illness (John 2020, Cochrane-Archer 2012, Woltmann 2012). CDM programs have also been shown to reduce hospital admissions or readmissions (Cochrane-Poot 2021, John 2020, Drewes 2012).

CDM programs, and the Chronic Care Model specifically, have been shown to improve health outcomes in patients with diabetes (Stellefson 2013b, Pimouguet 2011, Si 2008, CG-Diabetes), hypertension (John 2020, Pascucci 2021, CG-CVD 2015), anxiety and depression (John 2020, Cochrane-Archer 2012, Woltmann 2012), COPD (Cochrane-Poot 2021, Peytremann-Bridevaux 2008), and heart failure, including reducing mortality (Drewes 2012). In some cases, such interventions also improve outcomes for patients with asthma (Cochrane-Peytremann-Bridevaux 2015), osteoarthrosis (Brand 2014), and HIV (Pasricha 2013). Studies of CDM for patients with diabetes, asthma, and COPD indicate that using multiple components of the Chronic Care Model may increase program effectiveness (Baptista 2016, Lemmens 2009).

CDM improves quality of life for patients (John 2020), including patients with asthma (Cochrane-Peytremann-Bridevaux 2015), COPD (Cochrane-Poot 2021, Peytremann-Bridevaux 2008), heart failure (Drewes 2012), and anxiety and depression (Woltmann 2012). CDM may be more effective for patients with more severe mental illness than for those with less severe symptoms (Miller 2013b).

Interprofessional collaboration opportunities for health care providers implementing CDM programs can improve health outcomes for patients with chronic diseases and may increase preventive behaviors, such as smoking cessation (Pascucci 2021). Disease management interventions for patients with multiple chronic diseases may improve some health outcomes but additional evidence is needed to confirm effects (Cochrane-Smith 2016, Bleich 2015). Utilizing community health workers (CHWs) in CDM programs may improve primary care access and cancer screening (Mistry 2021, Kim 2016), and can be cost effective, especially for vulnerable populations (Kim 2016).

Patient-centered medical homes (PCMH) appear more effective than standard primary care models in chronic disease management (John 2020). Some evidence suggests programs that combine physician decision-support interventions with patient self-management support interventions may lead to the largest improvement in patient outcomes (Reynolds 2018a). However, further research is needed to evaluate which program components of disease management interventions and intervention duration is most effective for management of chronic diseases (Cochrane-Poot 2021).

It is unclear what impact chronic disease management (CDM) programs may have on disparities in chronic diseases.

People with one or more chronic diseases are at greater risk for disability, death, poor functional status, unnecessary hospitalizations, and many other challenges (Bleich 2015). Individuals from minoritized racial backgrounds (Price 2013), from rural areas (RHIhub-Chronic Disease), and those with low incomes are disproportionately more likely to have one or more chronic disease (Eyler 2019). Patients who are racial and ethnic minorities are almost twice as likely to be affected by major chronic diseases such asthma, diabetes, hypertension, obesity, and mental illness compared to patients who are white (Price 2013). Similar disparities exist between patients with different incomes: for example, diabetes rates are twice as high among adults with lower incomes than those with higher incomes (Eyler 2019). Rural residents, particularly those from minoritized backgrounds, are more likely to experience chronic diseases and have higher mortality rates than those in urban areas (Durfey 2019). People living in disadvantaged areas (i.e., with lower levels of safety, walkability, access to health care, nutritious foods, recreation, and higher levels of stress) are at higher risk for negative health outcomes, including hypertension and diabetes, and these communities are disproportionately Black. Hypertension and diabetes are less likely to be adequately managed in Black patients, regardless of income level (Durfey 2019).

The Federal Housing Administration’s redlining practices entrenched racial residential segregation in the U.S. and resulted in fewer health care facilities, resources, and funding in urban areas with largely Black populations (Lee 2023, Lee 2022c). Past residential redlining and present-day disparities in access to health care are associated with delays in disease diagnosis and treatment of health conditions, fewer preventive health visits, shortages of behavioral health clinicians, and larger Medicaid or uninsured populations in neighborhoods that are primarily Black and low income (Lee 2023). Formerly redlined neighborhoods are more likely to be near man-made environmental hazards producing pollution or toxins and have older homes in poor condition containing health hazards such as lead paint and mold (Braveman 2022), and residents continue to experience worse health outcomes, including chronic diseases like diabetes (Lee 2022c). Rural areas lack adequate access to physicians; approximately 20% of the U.S. population resides in rural areas, but only 10% of physicians provide care there (Arredondo 2023).

Chronic diseases have increased in prevalence over the last century as public health and modern medicine became increasingly effective in preventing and treating communicable diseases and are now the leading causes of death. Unlike diseases caused by single pathogens, chronic diseases are often the result of multiple factors accumulating over time, with aspects of the neighborhoods and communities individuals live in harming them by restricting their opportunities for healthy living (Hong 2019b). The chronic disease management (CDM) model emerged in the 1990s because of the increasing prevalence and complexity of treating patients with chronic illnesses (Wagner 1998).

• What are the disparities in chronic disease prevalence in your community? What groups are most affected?
• What resources are available for chronic disease management? Are certain groups less able to access the care and services available?
• What are the barriers to high quality linguistically and culturally appropriate chronic disease management services?
• How can chronic disease management services be more equitably delivered? What partnership opportunities exist in your community to increase access to these services?

There are many types of CDM programs. The Upper Great Lakes Family Health Center in Michigan is an example of a health center collaborating with local agencies to coordinate behavioral healthcare in a primary care setting to address and treat substance use disorder and depression (RHIhub-Cross Walk). Middlesex Hospital in Middletown, Connecticut’s program is an example of a hospital-based outpatient effort that serves the sickest patients with asthma, heart failure, obesity, and diabetes (Middlesex Health-CCM). The Sutter Care Coordination Program in the Sacramento Sierra region, which combines chronic care and disease management to address the medical and psychosocial needs of patients with multiple chronic conditions, is another example (Sutter Care Coordination Program).

As of January 2015, Medicare covers non-face-to-face chronic care management for patients with multiple chronic conditions who are at significant risk of death, acute exacerbation/decomposition, or functional decline (CMS-CCMS). The Centers for Medicare and Medicaid Services (CMS) Connected Care Toolkit can assist in the implementation of chronic care management programs (US DHHS-Connected Care Toolkit), and the National Center for Chronic Disease Prevention and Health Promotion within the Centers for Disease Control offers resources to advance equity in chronic disease prevention and management (CDC-Health Equity CCM).

‡ Resources with a focus on equity.

CDC-Health Equity CCM^‡ - Centers for Disease Control and Prevention (CDC). National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP).

Fromer 2011 - Fromer L. Implementing chronic care for COPD: Planned visits, care coordination, and patient empowerment for improved outcomes. International Journal of COPD. 2011;6:605–614.

Nordian-CCM - Nordian Healthcare Solutions. Chronic Care Management.

RHIhub-CCM - Rural Health Information Hub (RHIhub). Chronic Care Management.

US DHHS-Connected Care Toolkit^‡ - U.S. Department of Health and Human Services (U.S. DHHS). Chronic Care Management Toolkit: Chronic care management resources for health care professionals and communities.

* Journal subscription may be required for access.

Arredondo 2023 - Arredondo K, Touchett HN, Khan S, Vincenti M, Watts BV. Current programs and incentives to overcome rural physician shortages in the United States: A narrative review. Journal of General Internal Medicine. 2023;38:916-922.

Baptista 2016 - Baptista DR, Wiens A, Pontarolo R, et al. The chronic care model for type 2 diabetes: A systematic review. Diabetology & Metabolic Syndrome. 2016;8(1):1-7.

Bleich 2015 - Bleich SN, Sherrod C, Chiang A, et al. Systematic review of programs treating high-need and high-cost people with multiple chronic diseases or disabilities in the United States, 2008–2014. Preventing Chronic Disease. 2015;12:150275.

Brand 2014* - Brand CA, Ackerman IN, Tropea J. Chronic disease management: Improving care for people with osteoarthritis. Best Practice & Research Clinical Rheumatology. 2014;28(1):119-142.

Braveman 2022 - Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling. Health Affairs. 2022;41(2):171-178.

CCM - Improving chronic illness care. The Chronic Care Model (CCM): Model elements.

CDC-Health Equity CCM - Centers for Disease Control and Prevention (CDC). National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP).

CG-CVD 2015 - The Guide to Community Preventive Services (The Community Guide). Heart disease and stroke prevention: Cardiovascular disease (CVD).

CG-Diabetes - The Guide to Community Preventive Services (The Community Guide). Diabetes.

CMS-CCMS - Centers for Medicare & Medicaid Services (CMS), Medicare Learning Network (MLN). Chronic care management services (CCMS). U.S. Department of Health and Human Services (U.S. DHHS); 2015.

Cochrane-Archer 2012* - Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems (Review). Cochrane Database of Systematic Reviews. 2012;(10):CD006525.

Cochrane-Peytremann-Bridevaux 2015* - Peytremann-Bridevaux I, Arditi C, Gex G, Bridevaux PO, Burnand B. Chronic disease management programmes for adults with asthma (Review). Cochrane Database of Systematic Reviews. 2015;(5):CD007988.

Cochrane-Poot 2021 - Poot CC, Meijer E, Kruis AL, et al. Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2021;(9):CD009437.

Cochrane-Smith 2016* - Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings (Review). Cochrane Database of Systematic Reviews. 2016;(3):CD006560.

Drewes 2012 - Drewes HW, Steuten LMG, Lemmens LC, et al. The effectiveness of chronic care management for heart failure: Meta-regression analyses to explain the heterogeneity in outcomes. Health Services Research. 2012;47(5):1926–1959.

Durfey 2019 - Durfey SNM, Kind AJH, Buckingham WR, DuGoff EH, Trivedi AN. Neighborhood disadvantage and chronic disease management. Health Services Research. 2019;54:206-216.

Eyler 2019 - Eyler AA, Valko CA, Marti M, et al. Adjusting the equity lens: Gaps in addressing health equity in state chronic disease prevention. Health Equity. 2019;3(1):86-91.

Hong 2019b - Hong Y-C. Chapter 2: The age of chronic and late chronic diseases: A new view of diseases. In: The Changing Era of Diseases. Cambridge: Academic Press; 2019:35-68.

John 2020 - John JR, Jani H, Peters K, Agho K, Tannous WK. The effectiveness of patient-centred medical home-based models of care versus standard primary care in chronic disease management: A systematic review and meta-analysis of randomised and non-randomised controlled trials. International Journal of Environmental Research and Public Health. 2020;17(18):6886.

Kim 2016* - Kim K, Choi JS, Choi E, et al. Effects of community-based health worker interventions to improve chronic disease management and care among vulnerable populations: A systematic review. American Journal of Public Health. 2016;106(4):e3-e28.

Lee 2022c* - Lee EK, Donley G, Ciesielski TH, et al. Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis. Social Science and Medicine. 2022;294:114696.

Lee 2023* - Lee EK, Donley G, Ciesielski TH, Freedman DA, Cole MB. Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas. Social Science and Medicine. 2023;328:116009.

Lemmens 2009 - Lemmens KMM, Nieboer AP, Huijsman R. A systematic review of integrated use of disease-management interventions in asthma and COPD. Respiratory Medicine. 2009;103(5):670–691.

Middlesex Health-CCM - Middlesex Health. Chronic Care Management.

Miller 2013b - Miller CJ, Grogan-Kaylor A, Perron BE, et al. Collaborative chronic care models for mental health conditions: Cumulative meta-analysis and meta-regression to guide future research and implementation. Medical Care. 2013;51(10):922–930.

Mistry 2021 - Mistry SK, Harris E, Harris M. Community health workers as healthcare navigators in primary care chronic disease management: A systematic review. Journal of General Internal Medicine. 2021;36:2755-2771.

Pascucci 2021 - Pascucci D, Sassano M, Nurchis MC, et al. Impact of interprofessional collaboration on chronic disease management: Findings from a systematic review of clinical trial and meta-analysis. Health Policy. 2021;125(2):191-202.

Pasricha 2013 - Pasricha A, Deinstadt RTM, Moher D, et al. Chronic care model decision support and clinical information systems interventions for people living with HIV: A systematic review. Journal of General Internal Medicine. 2013;28(1):127–135.

Peytremann-Bridevaux 2008* - Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B. Effectiveness of chronic obstructive pulmonary disease-management programs: Systematic review and meta-analysis. The American Journal of Medicine. 2008;121(5):433–443.e4.

Pimouguet 2011 - Pimouguet C, Le Goff M, Thiébaut R, Dartigues JF, Helmer C. Effectiveness of disease-management programs for improving diabetes care: A meta-analysis. Canadian Medical Association Journal. 2011;183(2):E115–E127.

Price 2013 - Price JH, Khubchandani J, McKinney M, Braun R. Racial/ethnic disparities in chronic diseases of youths and access to health care in the United States. BioMed Research International. 2013:787616.

Reynolds 2018a - Reynolds R, Dennis S, Hasan I, et al. A systematic review of chronic disease management interventions in primary care. BMC Family Practice. 2018;19:11.

RHIhub-Chronic Disease - Rural Health Information Hub (RHIhub). Chronic disease in rural America.

RHIhub-Cross Walk - Rural Health Information Hub (RHIhub). Cross-Walk: Integrating Behavioral Health and Primary Care.

Si 2008* - Si D, Bailie R, Weeramanthri T. Effectiveness of chronic care model-oriented interventions to improve quality of diabetes care: A systematic review. Primary Health Care Research & Development. 2008;9(01):25–40.

Stellefson 2013b - Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in U.S. primary care settings: A systematic review. Preventing Chronic Disease. 2013;10:120180.

Sutter Care Coordination Program - Sutter Health. Sutter Care Coordination.

US DHHS-Connected Care Toolkit - U.S. Department of Health and Human Services (U.S. DHHS). Chronic Care Management Toolkit: Chronic care management resources for health care professionals and communities.

Wagner 1998* - Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.

WI DHS-CD - Wisconsin Department of Health Services (WI DHS). Chronic disease (CD) prevention and health promotion programs.

Woltmann 2012* - Woltmann E, Grogan-Kaylor A, Perron B, et al. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: Systematic review and meta-analysis. American Journal of Psychiatry. 2012;169(8):790–804.