Multiple Chronic Conditions: A Strategic Framework

Optimum Health and Quality of Life

for Individuals with Multiple Chronic Conditions

U.S. Department of Health & Human Services

December 2010

Contents

Foreword . . . . . 1

Background . . . . . 2

HHS Vision and Strategic Framework on Multiple Chronic Conditions . . . . . 6

Next Steps and Future Direction . . . . . 16

Citation

U.S. Department of Health and Human Services

—

Optimum Health and Quality of Life

for Individuals with Multiple Chronic Conditions.

December 2010.

Multiple Chronic Conditions: A Strategic Framework

Foreword

WearepleasedtopresentastrategicframeworkfortheU.S.DepartmentofHealthand

HumanServices(HHS)toimprovethehealthstatusofindividualswithmultiplechronic

conditions.Thisframeworkcontainsavisionstatement,goals,objectives,anddiscrete

strategiestoguidethedepartmentincoordinatingitseffortsinternallyand

collaboratingwithstakeholdersexternally.Theframeworkisdesignedtoaddressthe

spectrumofallpopulationgroupswithmultiplechronicconditions.

Acornerstoneofournation’sapproachtochronicdiseasesmustbetopreventtheir

occurrence.Anenhancedfocusonpreventionandpublichealthisessentialtoensuring

optimumhealthandqualityoflifeforallpeople.Inaddition,however,preventionisan

importantconsiderationforpersonswhoalreadyhaveoneormorechronicconditions.

Thisframework’sfocusisonimprovingthehealthandfunctionofpeoplewhocurrently

havemultiplechronicconditions.

Theintentionforthisframeworkistocatalyzechangewithinthecontextofhowchronic

illnessesareaddressedintheUnitedStates—fromanapproachfocusedonindividual

chronicdiseasestoonethatusesamultiplechronicconditionsapproach.Itisthis

culturechange,orparadigmshift,andthesubsequentimplementationofthese

strategiesthatwillprovideafoundationforrealizingthevisionofoptimumhealthand

qualityoflifeforindividualswithmultiplechronicconditions.

Multiple Chronic Conditions: A Strategic Framework

Background

MorethanoneinfourAmericanshavemultiple(twoormore)concurrentchronic

conditions(MCC),

including,forexample,arthritis,asthma,chronicrespiratory

conditions,diabetes,heartdisease,humanimmunodeficiencyvirusinfection,and

hypertension.Chronicillnessesare“conditionsthatlastayearormoreandrequire

ongoingmedicalattentionand/orlimitactivitiesofdailyliving.”

Inadditionto

comprisingphysicalmedicalconditions,chronicconditionsalsoincludeproblemssuch

assubstanceuseandaddictiondisorders,mentalillnesses,dementiaandother

cognitiveimpairmentdisorders,anddevelopmentaldisabilities.

Theprevalenceofmultiplechronicconditionsamongindividualsincreaseswithageand

issubstantialamongolderadults,eventhoughmanyAmericanswithMCCareunderthe

ageof65years.Asthenumberofchronicconditionsinanindividualincreases,therisks

ofthefollowingoutcomesalsoincrease:mortality,poorfunctionalstatus,unnecessary

hospitalizations,adversedrugevents,duplicativetests,andconflictingmedical

advice.

1,2, , , 3 4 5

Thispictureisevenmorecomplexassomecombinationsofconditions,or

clusters,havesynergisticinteractions,butothersdonot.

Forexample,thepoorhealth

outcomesofindividualswithseriousmentalillnessesandotherbehavioralhealth

problemswarrantsspecialattentionbecauseoftheco‐occurrencesofthoseconditions

withotherchronicconditions.

Theresourceimplicationsforaddressingmultiplechronicconditionsareimmense:66%

oftotalhealthcarespendingisdirectedtowardcarefortheapproximately27%of

AmericanswithMCC.

IncreasedspendingonchronicdiseasesamongMedicare

beneficiariesisakeyfactordrivingtheoverallgrowthinspendinginthetraditional

Medicareprogram.

IndividualswithMCChavefacedsubstantialchallengesrelatedto

theout‐of‐pocketcostsoftheircare,includinghighercostsforprescriptiondrugsand

totalout‐of‐pockethealthcare.



 AndersonG.ChronicCare:MakingtheCaseforOngoingCare.Princeton,NJ:RobertWoodJohnson

Foundation,2010.Availableathttp://www.rwjf.org/files/research/50968chronic.care.chartbook.pdf.

LastaccessedDecember2,2010.

 WarshawG.Introduction:advancesandchallengesincareofolderpeoplewithchronicillness.

Generation2006;30(3):5–10.(seealso:HwangW,WellerW,IreysH,AndersonG.Out‐of‐pocket

medicalspendingforcareofchronicconditions.HealthAffairs2001;20:267–278)

 LeeTA,ShieldsAE,VogeliC,GibsonTB,Woong‐SohnM,MarderWD,BlumenthalD,WeissKB.

Mortalityrateinveteranswithmultiplechronicconditions.JGenInternMed2007;22(Suppl3):403–

407.

 VogeliC,ShieldsAE,LeeTA,GibsonTB,MarderWD,WeissKB,BlumenthalD.Multiplechronic

conditions:prevalence,healthconsequences,andimplicationsforquality,caremanagement,and

costs.JGenInternMed2007;22(Suppl3):391–395.

 WolffJL,StarfieldB,AndersonG.Prevalence,expenditures,andcomplicationsofmultiplechronic

conditionsintheelderly.ArchInternMed2002;162(20):2269–2276.

 ThorpeKE,OgdenLL,GalactionovaK.ChronicconditionsaccountforriseinMedicarespendingfrom

1987to2006.HealthAffairs.2010;29(4):1–7.

Multiple Chronic Conditions: A Strategic Framework

Multiplechronicconditionscancontributetofrailtyanddisability;conversely,most

olderpersonswhoarefrailordisabledhaveMCC.TheconfluenceofMCCandfunctional

limitations,especiallytheneedforassistancewithactivitiesofdailyliving,produces

highlevelsofspending.Functionallimitationscanoftencomplicateaccesstohealth

care,interferewithself‐management,andnecessitaterelianceoncaregivers.

7

AreportbytheInstituteofMedicinein2001highlightedthecomplexitiesofandthe

needforcarecoordinationforindividualswithmultipleconditions.

Notingthatthereis

evidencethatpatientsreceivingcareforonechronicconditionmaynotreceivecarefor

other,unrelatedconditions,theIOMarticulatedthatachallengeofdesigningcare

aroundspecificconditionsistoavoiddefiningpatientssolelybytheirdiseaseor

condition.

8,9

TheChronicCareModelfurtherelucidatestheelementsrequiredto

improvechronicillnesscare,includingsystemsrequirementsforhealthcare

organization,communityresources,self‐managementsupport,deliverydesign,decision

support,andclinicalinformation.

Thisseminalmodelrepresentsaconceptual

foundationforinnovativeapproachestoaddressingMCC.

Overall,theMCCpopulationischaracterizedbytremendousclinicalheterogeneity,and

substantiallyvariesinthenumberofchronicconditions,theseverityofillnessand

functionallimitations,andtheclusteringofconditions.Indeed,developingmeansfor

determininghomogeneoussubgroupsamongthisheterogeneouspopulationisviewed

asanimportantstepintheefforttoimprovethehealthstatusofthetotalpopulation

andonlyrecentlyisbeginningtobeaddressedbyresearchers.

Identifyingsuch

subgroupswillassistinmoreeffectivelydevelopingandtargetinginterventions.A

relatedconsiderationisdisparitiesinaccesstohealthcare,publichealth,andother

services,whichmaypresentimplicationsforthepopulationofpersonswithMCC.

Thecombinedeffectsofincreasinglifeexpectancyandtheagingofthepopulationwill

dramaticallyincreasethechallengesofmanagingmultiplechronicconditionsamongthe

burgeoningpopulationofolderpersons.Althoughtherehasbeentacitappreciationof

thequalityofcareandcostimplicationspromptedbytheincreasingMCCpopulation,

thedeliveryofcommunityhealthandhealthcareservicesgenerallycontinuestobe

centeredaroundindividualchronicdiseases.Inaddition,insufficientattentionhasbeen

 AlecxihL,ShenS,ChanI,TaylorD,DrabekJ.IndividualsLivingintheCommunitywithChronic

ConditionsandFunctionalLimitations:ACloserLook.OfficeoftheAssistantSecretaryforPlanning&

Evaluation,U.S.DepartmentofHealthandHumanServices.January2010.Availableat

http://aspe.hhs.gov/daltcp/reports/2010/closerlook.htmLastaccessedDecember2,2010.

 CommitteeonQualityofHealthCareinAmerica,InstituteofMedicine.CrossingtheQualityChasm:A

NewHealthSystemforthe21stcentury.WashingtonD.C.:NationalAcademiesPress;2001.

 Redelmeier,DonaldA.,SiewH.Tan,andGillianL.Booth.Thetreatmentofunrelateddisordersin

patientswithchronicmedicaldiseases.NEngIJMed1998;338(21):1516–1520.

 WagnerE.Chronicdiseasemanagement:whatwillittaketoimprovecareforchronicillness?Effective

ClinicalPractice1998;1:2–4.

 KronickRG,BellaM,GilmerTP,SomersSA.TheFacesofMedicaidII:RecognizingtheCareNeedsof

PeoplewithMultipleChronicConditions.CenterforHealthCareStrategies,Inc.,October2007.

Multiple Chronic Conditions: A Strategic Framework

paidtotheservicesandsupportrequiredtomeetlonger‐termneedsofthosewithMCC

toenablethemtoliveaswellaspossibleincommunitysettings.

Role of the U.S. Department of Health and Human Services

TheU.S.DepartmentofHealthandHumanServicesadministersalargenumberof

federalprogramsdirectedtowardpreventingandmanagingchronicconditions,

including,forexample,financinghealthcareservices(CentersforMedicareand

MedicaidServices);deliveringcareandservicestopersonswithchronicconditions

(AdministrationonAging,HealthResourcesandServicesAdministration,andIndian

HealthService);conductingbasic,interventional,andsystemsresearch(Agencyfor

HealthcareResearchandQuality,NationalInstitutesofHealth);implementingprograms

topreventandmanagechronicdisease(CentersforDiseaseControlandPrevention,

andSubstanceAbuseandMentalHealthServicesAdministration);promotingthe

economicandsocialwellbeingoffamilies,children,individuals,andcommunities

(AdministrationforChildrenandFamilies);andoverseeingdevelopmentofsafeand

effectivedrugtherapies(FoodandDrugAdministration).

BecauseoftheleadingroleHHSplaysinhealthresearch,andpaymentforanddelivery

ofhealthcareservices,HHSalsomustprovideleadershipinimprovinghealthoutcomes

amongindividualswithMCC.Moreover,increasesinthecostsoftreating,poor

outcomesamong,andcomplexityofmanagingthosewithMCCnecessitatethatHHS

develop,implement,andcoordinateprogramsandpoliciesthatimprovethecare

providedtoindividualsandtheirhealth.Toachievethisgoal,HHSwillneedtoengage

stakeholdersinimplementingeffectivestrategiestoaddress,improve,andbetter

managethehealthstatusofindividualswithMCC.

Thehealthreformlaw—thePatientProtectionandAffordableCareAct—providesHHS

withnewopportunitiesforaddressingthepreventionofchronicconditions,aswellas

enhancingtheclinicalmanagementandimprovingthehealthstatusofindividualswith

MCC.Thislawwillfacilitatetheseadvancesthroughdevelopingandtestingofnew

approachestocoordinatedcareandmanagement,patient‐centeredbenefits,and

qualitymeasures.Newinitiativesalsowillbeaimedatenhancingtheunderstanding

amongpatientsandcaregiversabouttheappropriateuseofmedications.Stateswill

havetheoptionofproviding“healthhomes”forMedicaidenrolleeswithchronic

conditions.Importantly,thecreationofanewCenterforMedicareandMedicaid

InnovationwithinCMSpresentsunprecedentedopportunitiestoexamineandtestthe

mostpromisingapproachestocarecoordinationandhealthimprovement.

TwootherimportantnewinitiativesmandatedinthePatientProtectionandAffordable

CareActalsohaveimplicationsforpreventingandmitigatingchronicconditions:(1)the

NationalStrategyforQualityImprovementinHealthCare,whichwillincludepriorities

toimprovethedeliveryofhealthcare;and(2)theNationalPreventionandHealth

PromotionStrategy,whichaimstobringpreventionandwellnesstotheforefrontof

nationalpolicybyidentifyingandprioritizingactionsacrossmanysectorstoreducethe

Multiple Chronic Conditions: A Strategic Framework

incidenceandburdenoftheleadingcausesofdeathanddisability.Allofthoseefforts

canbeconnectedthroughHealthyPeople2020,whichwillestablishnationalhealth

objectivesandserveasthebasisforthedevelopmentofstateandcommunityplans.

HHS Interagency Workgroup

ToidentifyHHSoptionsforimprovingthehealthofthisheterogeneouspopulation,the 

HHSAssistantSecretaryforHealthconvenedadepartmentalworkgrouponindividuals

withmultiplechronicconditions.NearlyallHHSoperatingdivisionsareparticipating.

Theworkgroup’sinitialmajoreffortwastoproduceacollationofHHSprograms,

activities,andinitiativesfocusedonimprovingthehealthofindividualswithMCC.This

inventory,

releasedinMarch2009andslatedforupdate,containsmorethan50

effortsacrossHHSdirectedprimarilytothehealthcareneedsofpeoplewithtwoor

morechronichealthconditions.Inaddition,multipleinteragencyworkgroupmeetings

havebeenheldontopicssuchasreducingrehospitalizationsandadversedrugeventsin

thispopulation.TheworkgroupalsohasassistedHHSinbothhealthreformand

comparativeeffectivenessresearcheffortsrelatedtoMCC.Manyothereffortsthat

focusonthispopulationareunderwayacrossthedepartment.

Theworkgroupbelievesthat,amongotherbeneficialeffects,astrategicHHSframework

thatprovidesaroadmapforimprovingthehealthstatusofpersonswithMCCwillhelp

ensureamorecoordinatedandcomprehensiveapproachtoimplementingthe

considerableworkalreadydirectedtowardthisneed.Accordingly,theworkgroup

developedadraftofthisstrategicframeworkthatwasannouncedintheFederal

involvementisessentialtosuccessfulimplementationoftheframework,theFederal

frameworkandtoprovidefeedbacktothedepartment.Theworkgroupreviewed

commentsfromthepublicandstakeholderorganizationsandthenusedthemin

developingthisfinalversionofthestrategicframework.

 Availableathttp://www.hhs.gov/ophs/initiatives/mcc/mcc_inventory.pdf.

Multiple Chronic Conditions: A Strategic Framework

HHS Vision and Strategic Framework on

Multiple Chronic Conditions

Thevisionthatdrivesthedepartment’seffortsisOptimumHealthandQualityofLifefor

IndividualswithMultipleChronicConditions.Withinthevision’sfocusontheindividual

withMCC,developmentoftheframeworkelucidatedfourinterdependentdomainsthat

benefittheindividual:strengtheningthehealthcareandpublichealthsystems;

empoweringtheindividualtouseself‐caremanagement;equippingcareproviderswith

tools,information,andotherinterventions;andsupportingtargetedresearchabout

individualswithMCCandeffectiveinterventions.Accordingly,toachieveitsvision,this

frameworkcomprisesthesefouroverarchinggoals:

1. Fosterhealthcareandpublichealthsystemchangestoimprovethehealthof

individualswithmultiplechronicconditions

2. Maximizetheuseofprovenself‐caremanagementandotherservicesby

individualswithmultiplechronicconditions

3. Providebettertoolsandinformationtohealthcare,publichealth,andsocial

servicesworkerswhodelivercaretoindividualswithmultiplechronicconditions

4. Facilitateresearchtofillknowledgegapsabout,andinterventionsandsystems

tobenefit,individualswithmultiplechronicconditions

Eachofthesegoalsincludesseveralkeyobjectivesandstrategiesthatthedepartment—

inconjunctionwithstakeholdersandthosewhohaveorcareforthosewithmultiple

chronicconditions—shouldusetoguideitsefforts.Theseeffortsshouldbuildonand

potentiateHHSprogramsandresourcesfocusedontheMCCpopulation.Althoughthis

frameworkaddressesthoseindividualswithMCC,manyofthestrategies,includingthe

preventionofadditionalchronicconditions,alsoapplytopersonswithonlyoneorthose

withnochroniccondition.

Thepublicandprivatesectorsshareresponsibilityforimplementingtheseactivities.

HHSisparticularlygratefultothenumerousstakeholders—includingorganizationsand

individuals—thatprovidedinputtoHHSthroughthepubliccommentsprocessregarding

theframework’sgoals,objectives,andstrategies.HHSlookstobuildandstrengthen

partnershipswithallinterestedstakeholderstoachievetheseimportantgoalsfor

individualswithMCC.

Goal 1: Foster health care and public health system changes to improve the

health of individuals with multiple chronic conditions.

ImprovingthehealthstatusofpersonswithMCCrequiresheightenedcoordinationof

complexmedicalandlongitudinalpsychosocialcare.Moreover,personswithMCC

shouldhaveaccesstocommunityandotherpublichealthservices,aswellasimproved

medicalcarecoordination.Achievingthiscoordinationforindividualswithinasystem

comprisingnumerousindependentproviders,andincludingcoordinationacrossacute‐

andlong‐termcaresystems,hasbeendifficult.Unfortunately,thecurrentmodeloffee‐

Multiple Chronic Conditions: A Strategic Framework

for‐servicemedicalcareoffersfewfinancialincentivestocoordinatecare.Inaddition,

traditionaldiseasemanagementprograms—withoutastronglinktoprimarycareand

thatarefocusedondiscreteconditions—havenotbeenoptimallyeffective.

13,14

Changes

tothedeliveryandproviderpaymentsystem,developmentofaccompanyingquality

andperformancemetrics,andincreasedinvolvementofthepublichealthsystemcan

complementeffortstoachievewell‐coordinatedcareforthosewithMCC.

ObjectiveA:Identifyevidence‐supportedmodelsforpersonswithmultiplechronic

conditionstoimprovecarecoordination—Toaddressgapsincarecoordination,several

modelsthathaveemergedinrecentyearsemphasizepatient‐centeredmultidisciplinary

care,providercommunicationandcooperationtosmoothtransitionsacrosssettings,

andincorporationofpublichealthandcommunityresources.Thesemodelsinclude

patient‐centeredmedicalhomes,communityhealthteams,accountablecare

organizations,primarycareandbehavioralhealthintegrationmodels,

palliativecare,

andmodelsthatdeliverhealthcareservicesinthehomeandcommunitysettings.Those

modelsmayhaveanoverarchingeffectofenhancinghealthstatusamongindividuals

withMCC.Importantelementsforsuccessfulcarecoordinationincludeperson‐centered

carethatempowerstheaffectedindividualincaremanagement,team‐basedcare,and

alignedpaymentincentives.

• Strategy 1.A.1.DefineandidentifypopulationswithMCCbroadly,andMCC

subgroupswithspecificclustersofconditions,andexplorefocusingcaremodelson

thesubgroupsathighriskofpoorhealthoutcomes.(SeealsoStrategy4.B.3.)

• Strategy 1.A.2.Developandexpandpilotstudiesanddemonstrationprojectsfor

innovative,multidisciplinary,longitudinalperson‐centeredcaremodelsthat

improvehealthoutcomesandqualityoflifewhilemaintainingordecreasingnet

costs,andimplementevidence‐supportedmodels.

ObjectiveB:Defineappropriatehealthcareoutcomesforindividualswithmultiple

chronicconditions—ImprovedhealthcareoutcomesforindividualswithMCCcomprise

abroadspectrum,suchasmaintainingfunction,palliatingsymptoms,preventing

adversedrugevents,avoidingunnecessaryemergencydepartmentvisits,andreducing

hospitalizationsandrehospitalizations.Theseoutcomesarenotdifferentinkindfrom

relevantoutcomemeasuresforotherpersons,buttheydodifferinimportancebecause

oftheincreasedriskofnegativeoutcomesamongpersonswithMCC;forexample,as

 GeymanJP.DiseaseManagement:Panacea,anotherfalsehope,orsomethinginbetween.AnnFam

Med2007;5(3):257–260.

 PeikesD,ChenA,SchoreJ,BrownR.Effectsofcarecoordinationonhospitalization,qualityofcare,and

healthcareexpendituresamongMedicarebeneficiaries.JAMA2009;301(6):603–618.

 Forexample,Screening,BriefIntervention,andReferraltoTreatment(SBIRT,seealso:

http://sbirt.samhsa.gov/index.htm);andspecialtycaremedicalhomes(see:AlakesonV,FrankRG,Katz

RE.Specialtycaremedicalhomesforpeoplewithsevere,persistentmentaldisorders.HealthAffairs

2010;29:867–73).

Multiple Chronic Conditions: A Strategic Framework

thenumberofchronicconditionsincreasesinanindividual,sodoestheriskof

rehospitalization.



• Strategy 1.B.1.Definedesiredhealthcareoutcomesappropriateforindividualswith

MCC.

• Strategy 1.B.2.EnsurethattestingofcaremodelsincludesevaluationofMCC‐

relevantoutcomes.

ObjectiveC:Developpaymentreformandincentives—Healthcareprofessionalshave

fewincentivestoprovidecarecoordinationforindividualswithMCC,approachesthat

mayavoidpooroutcomessuchashospitalizationandrehospitalization.Moreover,

limitationsonreimbursementformanynonphysicianprovidersfurtherconstrain

multidisciplinarycaredeliverytoindividualswithMCC.Financialincentiveswould

encourageuseofcaremodelsthat,inturn,encouragerelevantcategoriesofproviders

tospendtheadditionaltimeneededtoaddressthecarecomplexitiesforthis

population.

• Strategy 1.C.1.Workwithstakeholderstoidentify,develop,andtestincentivesand

paymentapproaches(e.g.,episode‐basedpaymentsacrosscaresettings)that

promoteeffectivecarecoordinationforindividualswithMCC.

• Strategy 1.C.2.Disseminateinformationaboutandimplementtheuseofincentives

thatpromotecost‐effectivecarecoordinationbyproviderswhocareforindividuals

withMCC.

ObjectiveD:Implementandeffectivelyusehealthinformationtechnology—By

facilitatingcoordinatedcareandprovidinguniforminformationtoallproviderscaring

foranindividualwithMCC,interoperablehealthinformationtechnologyhasgreat

potentialtohelpclinicians,healthcaredeliverysystems,families,andindividuals

improvethequalityandsafetyofcareforthosewithMCC.

• Strategy 1.D.1.Encouragethemeaningfuluseofelectronichealthrecords,personal

healthrecords,patientportals,andclinicalregistriestoimprovecareforindividuals

withMCC.

• Strategy 1.D.2.Testandimplementtheuseofsecuremessagingandadditional

healthinformationexchangeplatforms(e.g.,telemedicineandremotemonitoring)

toimprovecareforindividualswithMCC.

• Strategy 1.D.3.Encouragetheuseofhealthinformationtechnologyasapublic

healthtoolformonitoringthepopulation’shealthandkeyperformancemeasures

relatedtomitigatingtheimpactofMCC.

 FriedmanB,JiangHJ,ElixhauserA.Costlyhospitalreadmissionsandcomplexchronicillness.Inquiry.

2008;45:408–421.

Multiple Chronic Conditions: A Strategic Framework

ObjectiveE.Promoteeffortstopreventtheoccurrenceofnewchronicconditionsand

tomitigatetheconsequencesofexistingconditions—Inadditiontoaddressinghealth

outcomesinpersonswithMCC,systemsshouldbestrengthenedandfullyusedfor

preventingtheoccurrenceofadditionalchronicconditions.

• Strategy 1.E.1.Developandimplementpreventivehealthandpublichealthsystems

approachesthatincreaseeffectivenessinthepreventionofnewchronicconditions

amongpersonswithMCC,includingconditionspotentiallyarisingfrominteractions

betweenexistingchronicconditionsortherapiesforthoseconditions,andthe

progressionandexacerbationofexistingchronicconditions.

• Strategy 1.E.2.Adoptpublichealthpolicies(e.g.,targetingunhealthyandrisky

behaviors,environments,andfoodsassociatedwithincreasedriskofchronic

disease)topreventexacerbationsoroccurrenceofnewchronicconditionsin

personswithexistingchronicconditions.

• Strategy 1.E.3.Exploreincentivestoimproveindividuals’participationinchronic

diseaseriskbehaviorandotherpreventionprograms.

ObjectiveF.Performpurposefuleval uationofmodelsofcare,incentives,andother

healthsysteminterventions—Monitoringandprovidingongoingfeedbackabout

interventionscanassistinimprovingboththeuseandimpactofinterventionsforMCC.

• Strategy 1.F.1.Conductongoingsurveillance—throughprovidersandindividuals

withMCC—oftheimpactandeffectivenessofinterventionsforMCC.

• Strategy 1.F.2.Dissemin a tefeedbacktoindividualswithMCC,providers,

researchers,andpolicymakersonneedsandoptionsformakingmoreeffectiveuse

of,andimproving,interventionsforMCC.

Goal 2: Maximize the use of proven self-care management and other

services by individuals with multiple chronic conditions.

EventhehighestqualityprovisionofcaretoindividualswithMCCalonewillnot

guaranteeimprovedhealthoutcomesforthispopulation.Individualsmustbeinformed,

motivated,andinvolvedaspartnersintheirowncare.

Self‐caremanagementcanbe

importantinmanagingriskfactorsthatleadtothedevelopmentofadditionalchronic

conditions.However,someindividualswithMCC(e.g.,thosewithsevereillnessor

substantialcognitivedecline)willbelimitedintheirabilitytoperformself‐care.The

importantrolethatfamiliesandothercaregiversprovideinmanagingchronic

conditionsmustberecognizedandsupported.



 GreenhalghT.Chronicillness:beyondtheexpertpatient.BMJ2009;338:629–631.

Multiple Chronic Conditions: A Strategic Framework

ObjectiveA:Facilitateself‐caremanagement—Chronicdiseaseself‐caremanagement

programshavegeneratedasignificantevidence‐base.

18, 19

Translatingandreplicating

theseprogramsinmultiplesettings(e.g.,healthcare,home,work,andassistedliving)

willimprovethehealthstatusoftheMCCpopulation.

• Strategy 2.A.1.Continuallyimproveandbringtoscaleevidence‐based,self‐care

managementactivitiesandprograms,anddevelopsystemstopromotemodels

thataddresscommonriskfactorsandchallengesthatareassociatedwithmany

chronicconditions.

• Strategy 2.A.2.Enhancesustainabilityofevidence‐based,self‐management

activitiesandprograms.

• Strategy 2.A.3.Improvetheefficiency,quality,andcost‐effectivenessofevidence‐

based,self‐caremanagementactivitiesandprograms.

ObjectiveB:Facilitatehomeandcommunity‐basedservices—Homeandcommunity‐

basedservices(HCBS)oftenplayacriticalroleinenablingindividualswithMCCtolive

andworksuccessfullyintheircommunities.Evidence‐basedprogramsandserviceshave

beendevelopedinrecentyearstoassisttheMCCpopulationinattaininghealthierand

moreindependentlives.ExamplesofsuchprogramsarethosethatretrainMedicaid

homehealthaidestoprovideappropriatehome‐basedphysicalactivitytrainingto

beneficiaries;deliverHCBSthatpreventfalls;andprovidepeersupporttoreducethe

severityofdepressivesymptoms.Otherinnovationsincludehome‐basedinformation

technologyandcommunity‐basedorganizationsthatprovidecaretransitionservices.

• Strategy 2.B.1.ImproveaccesstoeffectiveHCBSfortheMCCpopulationthrough

informationandreferral,optionscounseling,andsmoothcaretransitions.

• Strategy 2.B.2.Improveinfrastructure(e.g.,telemonitoringandsharedinformation

services)tosupportHCBS,andpromoteeducationalandtechnologicalinnovations

thatpermitindividualswithMCCtoremainmaximallyfunctionalandindependent,

understandandbettermanagetheirconditions,andresidesafelyintheirhomesor

othersettings.

• Strategy 2.B.3.Providetrainingandinformationonevidence‐basedself‐care

managementto,andimprovesupportsfor,familycaregivers.

ObjectiveC:Providetoolsformedicationmanagement—Asthenumberofchronic

conditionsincrease,sodothenumberofmedicationsprescribedandthedegreeof

nonadherencetoregimens.

Inadditiontoreducingadversedrugeventsand

medicationerrors,toolstoimproveknowledgeableuseofmedicationsmayreduce

chronicdiseaseprogression.

 Selectedpublicationsathttp://patienteducation.stanford.edu/bibliog.html.

 Selectedpublicationsathttp://www.ahrq.gov/qual/ptmgmt/ptmgmtap1.htm

20

TinettiME,BogardusST,AgostiniJV.Potentialpitfallsofdisease‐specificguidelinesforpatientswith

multipleconditions.NewEnglJMed2004;351(27):2870–2874.

Multiple Chronic Conditions: A Strategic Framework

• Strategy 2.C.1.Developanddisseminateshareddecision‐makingandothertools

forindividualswithMCCtoprovideaccessibleinformationabouttreatmentchoices

andimproveadherencetomedicationregimens.

• Strategy 2.C.2.Identifyordevelopandthendisseminatetoolstohelpindividuals

withMCCandtheircaregiversrecognizedrug‐druginteractionsandpotential

adversedrugeventsfromcomplexmedicationregimens.

• Strategy 2.C.3.Fosterimprovedandculturallyappropriatehealthliteracyto

facilitatebetterinformeddecision‐makingaboutuseofmedications.

Goal 3: Provide better tools and information to health care, public health,

and social services workers who deliver care to individuals with multiple

chronic conditions.

Healthcare,publichealth,andsocialservicesprofessionalsandfamilycaregivers

practiceinavacuumofpublisheddataregardingcareforthosewithmultiplechronic

conditions.Providingtheseprofessionalsandfamilycaregiverswiththetoolsand

informationtheyneedtocareforindividualswithMCCiscriticaltoimprovecare

provision.Moreover,becausemostmanagementofchronicconditionsoccursoutside

themedicalcaresetting,attentionmustbefocusedacrossthecarecontinuumbothto

sustainandimproveadherencewithpreventionandtreatmentstrategiesforimproved

healthoutcomes.

ObjectiveA:Identifybestpracticesandtools—TheMCCpopulationisclinically

heterogeneous.Irrespectiveofthespecificcombinationsofchronicconditions,there

likelyaregeneralapproachesthatfacilitateimproved,optimizedcare.Thegoalof

identifyingindividualbestpracticesistopromoteasystematicapproachtothe

assessmentandmanagementofthiscomplexpopulation,includingthepreventionof

additionalco‐morbidities.

• Strategy 3.A.1.Identify,develop,disseminate,andfosterintegrationofbest

practicesinformationrelevanttothegeneralcareofindividualswithMCC.



• Strategy 3.A.2.Identify,develop,endorse,andusekeyqualitymetrics,intheform

ofperformancemeasures,topromotebestpracticesinthegeneralcareof

individualswithMCC.

• Strategy 3.A.3.Identify,develop,andvalidatematerialsthatassistprovidersin

educatingindividualswithMCCandfamilycaregiversinappropriateself‐careand

shareddecision‐making.



21

Examplesofcareareasmayincludechronicpain,mentalandcognitivehealth,nutrition,physical

activity,medicationmanagement,transitionalcare,andcommunicationstructuresforinter‐

professionalcarecoordination.

Multiple Chronic Conditions: A Strategic Framework

• Strategy 3.A.4.Developanddisseminatetoolsforusebyandacrossdifferent

organizations,providers,andfamilycaregiversthatimprovetheuseand

managementofmedications,includingpromotionofknowledgeableuseof

medications,reductionofprescriptionofinappropriatemedications,andreduction

ofpatientrisksassociatedwithpolypharmacy.

ObjectiveB:Enhancehealthprofessionalstraining—Healthcare,publichealth,and

socialservicesprofessionalsaredependentonandinfluencedbytrainingprogramsthat

preparethemfortheenvironmentsinwhichtheywillpractice.Evidencesuggeststhat

manyhealthcareprofessionaltraineesfeeluncomfortablewithkeychroniccare

competencies.

Addressingthesegaps,aswellastheneedforimprovingproviders’

culturalcompetencies,willensurethatthecurrentandnextgenerationsofproviders

areproficientincaringforindividualswithMCCandininteractingwithfamily

caregivers.

• Strategy 3.B.1.Identifyordevelopinformationrelevanttothegeneralcareof

individualswithMCCforuseinhealthandsocialserviceprofessionaltraining

programs.

• Strategy 3.B.2.Disseminateinformationrelevanttothegeneralcareofindividuals

withMCCtoallHHS‐fundedorsupportedhealthandsocialserviceprofessional

trainingprogramsforinclusioninrequiredcurricula,asappropriate.

• Strategy 3.B.3.Ensurethathealthcare,publichealth,andsocialservices

professionalsreceivetrainingonmonitoringthehealthandwellbeingoffamily

caregiversforindividualswithMCC.

• Strategy 3.B.4.Developandfostertrainingwithinbothtraditionaland

nontraditionalprofessionalsettings(e.g.,medicine,nursing,socialwork,

psychology/counseling,clinicalpharmacy,chaplaincy,vocationalrehabilitation,

communityhealthworkers)thatemphasizesincreasedcompetencyinpalliative

andpatient‐centeredapproaches.

ObjectiveC:Addressmultiplechronicconditionsinguidelines—Evidence‐based,

person‐centeredclinicalguidelinesassisthealthcareprovidersinprovidinghighquality

caretoindividuals.Moreoftenthannot,guidelinesonspecificchronicconditionsdonot

takeintoaccountthepresenceofMCCand,importantly,howtheseco‐morbiditiesmay

affectthetreatmentplan.

Moreover,guidelinesforpersonswithmentalillnessand

substanceabuserarelyaddresstheco‐occurrenceofotherchronicconditions.Asthe

evidencebasegrowstofacilitategreaterspecificityinguidelines(seealsoGoal4.C.),

 DarerJD,HwangW,PhamHH,BassEB,AndersonG.Moretrainingneededinchroniccare:asurveyof

USphysicians.AcadMed2004;79(6):541–548.

 BoydCM,DarerJ,BoultC,FriedLP,BoultL,WuAW.Clinicalpracticeguidelinesandqualityofcarefor

olderpatientswithmultiplecomorbiddiseases:implicationsforpayforperformance.JAMA

2005;294(6):716–724.

Multiple Chronic Conditions: A Strategic Framework

thosewhodevelopguidelinesmustfocusonusingsuchevidence.Betterincorporation

ofrelevantinformation,howeverlimited,willenhanceguidelines’applicabilitytoan

increasingnumberofindividualswithMCC.

• Strategy 3.C.1.Ensurethatdevelopersofguidelinesincludeinformationonthe

mostcommoncomorbiditiesclusteringwiththeincidentchronicconditionandon

themanagementofriskfactorstopreventtheoccurrenceofadditionalchronic

conditions.

• Strategy 3.C.2.Ensurethatclearinghousesorrepositoriesofchronicdisease

guidelinesencouragelabelingandpromotionofselectedguidelinesthat

incorporateinformationonindividualswithMCC.

Goal 4: Facilitate research to fill knowledge gaps about, and interventions

and systems to benefit, individuals with multiple chronic conditions.

SignificantgapsexistintheapproachtocareforindividualswithMCC.Bolstering

researcheffortswillenableimprovedcharacterizationoftheMCCpopulation,support

healthcareandotherprovidersincoordinatingandmanagingcareforthispopulation,

andassistintrackingprogressinimprovinghealthforindividualswithMCC.Thisgoal

encompassesabroadspectrumofresearchconsiderations,including,forexample,basic

investigationofmedicaltherapies,epidemiologicstudyoftheimpactofcomorbidities

ondiseasetrajectories,efficacyandeffectivenessofpromisinginterventionsforhealth

promotionandself‐management(asdescribedinGoal2),andhealthsystemcare

managementstrategies(asdescribedinGoal1).

ObjectiveA:Increasetheexternalvalidityoftrials—Asthenumberofindividualswith

MCCgrows,ensuringthattreatmentinterventions(e.g.,drugs,devices,lifestyle

modifications,alternativemedicine)fortheseconditionsaresafeandeffectivebecomes

moreimportant.Toachievethisend,effortstoimproveunderstandingofinteractions

betweencomorbiditiesandtolimitexclusionsofthisincreasinglylargepopulationin

clinicaltrialsmayassistinpreventingadverseeventsandpooroutcomesthatotherwise

mighthaveoccurredifthispopulationwerenotincludedinthestudydesign.

• Strategy 4.A.1.DevelopmethodstoassesstheinclusionofindividualswithMCCin

clinicaltrials.Suchmethodsshouldincludedetermining1)optimaltrialdesignsfor

includingMCCpatients;2)optimalapproachesforrecruitingMCCpatients;3)the

potentialrisksofexposingsomeMCCpatientstonewinterventions;and4)the

appropriateanalysisofoutcomesdatafromclinicaltrialsthatincludeindividuals

withMCC.

• Strategy 4.A.2.ImprovetheexternalvalidityofHHS‐fundedcommunityandclinical

interventiontrialsbyensuringthatindividualswithMCCarenotunnecessarily

excluded(asdeterminedbyscientificexpertsandexternalstakeholders).

• Strategy 4.A.3.Ensure,throughguidanceorregulation,thatindividualswithMCC

arenotunnecessarilyexcludedfromclinicaltrialsfortheapprovalofprospective

drugsanddevices.

Multiple Chronic Conditions: A Strategic Framework

• Strategy 4.A.4.Assessandstrengthenpostmarketingsurveillanceforpotential

intervention‐relatedadverseeventsandpooroutcomesamongindividualswith

MCC.

ObjectiveB:Understandtheepidemiologyofmultiplechronicconditions—Limited

researchhasyieldedinformationabouttheconstellationsofconditionsthataremost

prevalentandmostimportantintermsofdisabilityamongindividualswithMCC.

ing

er

n

dsofMCC.

• Strategy 4.B.2.DeterminethedistributionofMCCforMedicareandMedicaid

italsandclinics,andusethisinformationtoplan

o



havebeenwellcharacterizedintheliterature.Therefore,

eate

C.

ups—

y‐

systemstobestsupport

ns

:thisstrategybuildsuponworkcalledforin

AdditionalresearchidentifyingthemostcommonpatternsofMCCcanhelpintarget

specificinterventionsforspecificsubgroupsandmonitoringtheimpactofthose

interventions.Suchresearchshouldutilizepublicprogram(e.g.,Medicare)andoth

existingdatasets.

• Strategy 4.B.1.Stimulateepidemiologicalresearchtodeterminethemostcommo

dyadsandtria

beneficiaries,aswellasclientsofHRSA‐fundedcommunityhealthcentersand

IndianHealthServicehosp

interventionsandmonitortheireffectiveness.

• Strategy 4.B.3.Developtoolstoidentifyandtargetpopulationsubgroupsof

individualswithMCCwhoareathighriskforpoorhealthoutcomes.(Seeals

Strategy1.A.1.)

ObjectiveC:Increaseclinical,community,andpatient‐centeredhealthresearch—

Neitherthetreatmentofcomorbiditiesnortheimpactofcomorbiditiesonpatients’

healthstatusovertime

researchthatelucidatestheevidencebasefortheprevention,management,and

treatmentofindividualswithMCCisurgentlyneeded.Researchthatexpandsthe

capacityofclinicianstodirectcaretowardoutcomesofhighestimportanceto

individualswithMCCwillbeessential,aswillbeexaminationofthepoliciesthatcr

disincentivesforproviderstoadequatelyaddresstheneedsofindividualswithMC

Feedbackonresearchprogressshouldbeprovidedtothepublicandtokeygro

includingindividuals,providers,researchers,andpolicymakers—onapproachesfor

reducingbarrierstoandimprovinginterventionsforMCC.

• Strategy 4.C.1.Expandresearchontheoptimalclinical,self‐care,andcommunit

basedapproachesforhealthpromotion,diseaseprevention,andhealthcare

managementofindividualswithMCC,aswellasonthe

andsustainthisprogramming.

• Strategy 4.C.2.Innovateandstrengthenmethodsforresearcherstoimprove

measurementofpatient‐centeredoutcomesoftreatmentsandotherinterventio

forindividualswithMCC.(Note

Strategy1.B.)

Multiple Chronic Conditions: A Strategic Framework

• Strategy 4.C.3.Improveknowledgeaboutpatienttrajectoriestemporallyinrelation

tochangesinhealth



status,functionalstatus,andhealthservicesuse.

Itislikely

thatasracialandethnic,gender,genderidentity,disability,sexualorientation,age,



tomoreclearlyelucidatedifferencesbetween

andopportunitiesforpreventionandinterventioninMCCamongvarious

riskand

rageHHSdisparitiesprogramsandinitiativestoaddress

ObjectiveD:Addressdisparitiesinmultiplechronicconditionspopulations—

geographic,andsocioeconomicdisparitiesofaccesstocareandhealthoutcomesexist

inthetotalpopulation,thosedisparitiesalsoexistintheMCCpopulation.Additional

researchdirectedtowardunderstandingtherolesofdisparitiesintheMCCpopulation

wouldassistinfocusinginterventions.

• Strategy 4.D.1.Stimulateresearch

sociodemographicgroups.

• Strategy 4.D.2.Useresearchfindingsongroup‐specificindicatorsforMCC

interventionoptionstoleve

theMCCpopulation.

Multiple Chronic Conditions: A Strategic Framework

Next Steps and Future Direction

Theagingofthepopulation,thecontinuedexistenceofchronicdiseaseriskfactors(e.g.,

tobaccouse,poornutrition,lowphysicalactivitylevels),andthemarvelsofmodern

medicinewillcontributetoincreasingnumbersofAmericanswithmultiplechronic

conditions.ThemajorityofindividualswithchronicdiseasesintheUnitedStatesalso

havemultiplechronicconditions.Nowisthetimetoviewperson‐centeredchronic

diseasepreventionandcaremanagementthroughtheprismofMCC.

Theimpactofmultiplechronicconditionsrepresentsmorethanthesumoftheirparts.

Multiplechronicconditionscanoverwhelmindividuals,theirfamiliesandotherswho

careforthem,healthcareprofessionalsandotherserviceproviders,andoursystemsof

careintheUnitedStates.HHS,inconcertwithnumerousstakeholders,hasdeveloped

theinterlinkedstrategiesinthisframeworktohelpindividualswithMCC,theirfamilies,

healthcareproviders,healthcareandpublichealthsystems,andcommunitiesto

identifyandimplementapproachestooptimizinghealthandqualityoflife,whilealso

reducingtheburdensofmultiplechronicconditions.ThisframeworkwillhelpHHSto

identifygapsinitseffortstoaddressthehealthstatusofindividualswithMCC,andin

developinginitiativestosupporttheimplementationofmanyofthestatedstrategies.

TheHHSStrategicFrameworkbuildsuponexistingresourcesandeffortsandprovides

guidancefordevelopingfutureapproaches.HHSwillseektocontinueengagingwiththe

publicandprivatesectorsaseffortsmoveforwardtoadopt,implement,and,when

indicated,furthermodifytheframework.TheInteragencyWorkgrouponMultiple

ChronicConditionswillcontinueassistingHHSinensuringacoordinatedand

comprehensiveeffortformovingforward.Partnershipsbetweenthepublicandprivate

sectorswillbecriticaltoachievingthevisionofOptimumHealthandQualityofLifefor

IndividualswithMultipleChronicConditions.