Living Well with Chronic Illness: A Call for Public Health ActionIOM Committee on Living Well with Chronic Illness

Background Information

●Chronic Illnesses have emerged as major health burden:● Increasing in prevalence and incidence●Great impact on quality of life●Major cost implications

● In 2010, the CDC and the Arthritis Foundation sought assistance from the IOM to: ● Identify population-based, public health actions that can help reduce

disability● Improve functioning and quality of life among individuals who are at

high risk of developing a chronic illness and those with one or more chronic illnesses.

Statement of Task

The sponsors advised the 17 member committee to focus thedeliberations and recommendations in the report to:

• Identify the consequences of chronic diseases that are most important to the nation’s health and economic well-being.

• Identify which chronic diseases and populations should be the focus of public health efforts to reduce disability and improve quality of life.

• Identify which population-based interventions can help achieve outcomes that maintain or improve quality of life, functioning, and disability.

• Identify ways to highlight the morbidity of arthritis and influence systematic change to improve the lives of those living with arthritis.

• Recommend population-based public health actions and strategies for implementation.

Committee Approach

The committee’s work:

●5 in-person meetings;●Extensive literature reviews and internet searches

regarding an array of topics areas related to chronic illness;

●Meetings related to public health and chronic disease prevention as part of the information-gathering process;

●Two public workshops; and●Commissioned two experts to develop papers on specific

topics to supplement the report.

Overall Intent

●The report Living Well with Chronic Illness: A Call for Public Action is a guide for immediate and precise action to reduce the burden of all forms of chronic illness through the development and implementation of cross-cutting and coordinated strategies to help Americans live well.

●The report and its recommendations are rooted in a population-based approach to support living well, with emphasis on the importance of public health action and leadership in the management of chronic disease.

LWWCI: Some Underlying Themes

●An inclusive definition of “chronic illness”● Including illnesses of all causes and multiple chronic conditions

●Attention to disadvantaged and minority populations●The need to understand the natural history of chronic illnesses

across the lifecourse●The complex interface of public health and clinical chronic

disease management programs●Improved national surveillance●The need for a new round of strategic planning with between

federal and state public health agencies●Greater inclusion of quality-of-life measures

Multiple Chronic Conditions

●MCCs woven into the report in many places●Current literature just beginning to deal with the

complexity (biologic; taxonomic; therapeutic)●The need for research on optimal public health

interventions●Distinguishing between disease variation, natural

history and long-term consequences

Where Public Health Interventions Can Occur(And the Issue of MCCs)

Lifecourse

Chronic Illness

Primary Prevention Secondary

Outcomes

Secondary

Prevention

Other Int’ns

The Approach to Selecting Illnesses for Control: A Menu, Not a List

Rationale:

●CDC/state programs have addressed most common and severe problems

●Objective criteria for public health import often orthogonal

● Disability, QALYs, DALYs, YLLs, Morbidity, Economic Cost, Morbidity, Mortality, etc.

●Desire for inclusiveness of a broad range of conditions

●Cross-cutting symptoms as well as named conditions

●Living with the fear/prospects of disease

●Economic considerations

●Attention to social consequences of illness

●Programmatic discretion in chronic illness control programs

●Proceed where proven program effectiveness (Winnable Battles)

Environmental & Population-based policy interventions to support healthy living and

primary prevention

Community-wide strategies that link with health care to support self-care, provide risk factor treatment, & prevention complications

Intensive strategies aligning health care & and nonhealth care sectors to maximize

quality of life & reduce complications

High-intensity interventions designed specifically to address the unequal burden of

chronic disease in high-priority groups

Priority Pyramid Intervention Targets

Refinement guided by coordinated surveillance of

living well outcome metrics

An Exemplar (Natural History) Approach to Chronic Illness Management

● Presents an alternative approach to public health chronic disease control

● Validates the notion that all chronic illnesses have the potential to limit functional status, productivity and quality of life of people who live with them

● Avoids the trap of pitting one disease against another● Looks at a broad set of clinical manifestations and other

important consequences experienced by individuals living with chronic illness

● Allows for surveillance efforts, populations-based interventions and policies to be developed to capture and address a wide range of illnesses

The “Exemplars:” A Disease History Approach (See details in Chapter 2)

●Arthritis (degenerative and rheumatoid)●Cancer survivorship●Chronic pain●Dementia●Depression●Type 2 diabetes●Post-traumatic disabling conditions●Schizophrenia●Vision and hearing loss

An Elaborated Model for Chronic Disease Care

A Renewed Emphasis on Community-Based Interventions in Public Health

Lifestyle:

Physical activity Tobacco

Diet Screening & Vaccines

Self-health management Weight control

Disease management Respite care

Treatment adherence Peer support

CAM Caregiver support

Cognitive training/ literacy Access and mobility

The need for monitoring, evaluation and research

Extending Public Health Interventions: the Critical Role of the Workplace

●Implementation of pilot health promotion programs to various types of workplaces for those with chronic illnesses

●Provision of incentives to employers●Emphasis on:●Low wage employers●Small businesses

The Importance of Policy

●See other reports from IOM and elsewhere (e.g., Law and Public Health)

●Defining “policy” and its barriers ●The role of values in policy formulation●Policies of great current interest:●Socio-economic status●Access to care●Transportation●Independent living●Mobility (e.g., ADA)●Care quality initiatives

●Affordable Care Act: Implications for public health and prevention

New Imperatives for Surveillance of Chronic Illnesses

●Expand the clinical dimensions of illness●Symptoms ●Function●Health-related quality of life●Survivorship●Adverse effects of public health and clinical interventions●Longitudinal assessment of individuals and groups ●Patient participation in chronic care management●Care models; self-management●Public health and prevention programs and venues

Greater Use of Newer Economic Methods for Supporting Public Health Interventions

●Cost benefit and cost effectiveness methods●Emphasize long term outcomes●For selected illnesses of public health importance:

methods used for national health accounts●Opportunity costs of various public health programs●Interventions addressing multiple chronic interventions

Collaboration among Public Health, Prevention and Community Sectors

●Structures/approaches that support population health●Maintaining public health indicators●Responding to emerging population health threats●Alignment of public health and clinical interventions●System design●Incentives●Fuller and more innovative use of community venues

for LWWCI

Recommendations

The secretary of HHS should support the states in developing comprehensive population-based strategic plans with specific goals, objectives, actions, time frames, and resources that focus on the management of chronic illness among their residents, including community-based efforts to address the health and social needs of people living with chronic illness and experiencing disparities in health outcomes.

Such strategic plans should also include steps to collaborate with community-based organizations, the health care delivery system, employers and businesses, the media, and the academic community to improve living well for all residents with chronic illness, including those experiencing disparities in health outcomes.

Recommendations, con’t

The committee recommends that the Secretary of HHS and the CDC should explore and test a Health in All Policies approach with Health Impact Assessments as a promising practice on a select set of major federal legislation, regulations, and policies, and evaluate its impact on health related quality of life, functional status, and relevant efficiencies over time.

Recommendations, con’t

The committee recommends that CDC:

1. Continue to review the scientific literature to monitor for potential MCC taxonomies that are

useful for planning, executing and evaluating disease control programs of MCC occurrences.

2. Explore surveillance techniques that are more likely to capture MCCs effectively. This should

include not merely counting the co-occurrence of diseases and conditions, but also the order of

occurrence and the impact on quality of life and personal function.

3. Emphasize MCC prevention by testing and evaluating a set of public health interventions

aimed at preventing or altering the course of new disease occurrences in individuals with MCC,

or who are at risk for them. This might include established approaches, such as tobacco control

or experimental approaches such as metabolic or genetic screening.

4. Increase demonstration chronic disease control programs that cut across specific diseases or

multiple chronic conditions and emphasize mitigating the secondary consequences of a variety

of chronic conditions, such as falls, immobility, sleep disorders and depression.

IOM Committee Members

ROBERT B. WALLACE (Chair), University of Iowa, Iowa CityRONALD T. ACKERMANN, Northwestern University Feinberg School of Medicine, Chicago, ILKAREN BASEN-ENGQUIST, The University of Texas, MD Anderson Cancer Center, HoustonBOBBIE A. BERKOWITZ, Columbia University School of Nursing, New York, NYLEIGH F. CALLAHAN, The University of North Carolina at Chapel HillRONNI CHERNOFF, Geriatric Research Education and Clinical Center, Central Arkansas Veterans Healthcare System and Arkansas Geriatric Education Center, University of Arkansas for Medical Sciences, Little RockDAVID B. COULTAS, The University of Texas Health Science Center at TylerSHERITA HILL GOLDEN, Johns Hopkins University School of Medicine, Baltimore, MD

IOM Committee Members, cont.

JEFFREY R. HARRIS, University of Washington School of Public Health, SeattleRUSSELL HARRIS, University of North Carolina at Chapel HillKATIE B. HORTON, The George Washington University School of Public Health and Health Services, Washington, DCM. JEANNE MIRANDA, Center for Health Services Research, University of California, Los AngelesMARCIA NIELSEN, Patient Centered Primary Care Collaborative, Washington, DCOLUGBENGA G. OGEDEGBE, New York University Lagone Medical Center, New York CityPATRICK REMINGTON, University of Wisconsin School of Medicine and Public Health, MadisonDAVID B. REUBEN, David Geffen School of Medicine University of California, Los AngelesMICHAEL SCHOENBAUM, National Institute of Mental Health, Bethesda, MD

IOM Study Staff

E. LORRAINE BELL, Senior Study Director

PAMELA LIGHTER, Research Assistant

CHELSEA FRAKES, Senior Program Assistant

ANDREW LEMERISE, Research Associate

HOPE HARE, Administrative Assistant

AMY PRYZBOCKI, Financial Associate

ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health Practice