Coordination of care helps patients manage disease

Chronic care model links providers, community

The only way to help people with chronic illnesses manage their disease is to develop a care management protocol that extends through the entire disease process from the acute care episode to the community and back to the acute care facility, says Donna Zazworsky, RN, MS, CCM, FAAN, manager of network diabetes care, faith community nursing and telemedicine for Carondelet Health Network in Tucson, AZ.

"So often we work in an organization where patients come in because they're already sick and we are reacting to what is presented. We need to develop ways to be proactive and screen people ahead of time to identify those who are at risk for a disease to help them avoid it and to help those with the disease keep it under control," Zazworsky says.

Case management across the continuum is the key to helping people manage their chronic diseases and keeping them out of the hospital, she adds.

"Evidence suggests that providing high-quality chronic care involves more than just adding additional interventions; linkage between the health care delivery system and the community plays a big role," she says.

For a treatment plan to succeed, health care providers must link the patient to outside resources such as exercise, weight management, and diabetes programs and collaborate with staff at community organizations and agencies to coordinate care, she adds.

"Everyone needs to work as a team to coordinate patient care. We need to all know our roles and tasks," she says.

Zazworsky is a proponent of the chronic care model, which extends health care beyond the provider or health plan and incorporates community-wide efforts to improve clinical outcomes.

For instance, in Tucson, St. Elizabeth Health Center, a faith-based community health center serving the uninsured and underserved, has collaborated with other community agencies and developed a comprehensive program for diabetics that provides recommended care at a reduced cost and co-pay.

The chronic care model is an evidence-based model that takes an organized approach to treating people with chronic diseases and emphasizes the patient's role in managing his or her disease, Zazworsky adds.

The model extends care beyond the health care system and into the community to provide better functional and clinical outcomes, she says.

"The issues related to the cost of chronic care are profound," Zazworsky points out.

For instance, total diabetes spending tops $98 million in a year, she says. A person without diabetes incurs an average of $2,669 in health care costs each year. Health care for diabetics on average cost $10,071 a year.

Each year, diabetics have a mean hospital stay of 5.4 days, for a total of 13.9 million days and a cost of $72.5 billion. Patients make 30.3 diabetes-related visits to the doctor each year and generate $10.9 billion in outpatient costs.

Americans with diabetes account for 15% of national health care costs, although they make up only 5% of the population, Zazworsky adds.

An additional 15% to 20% have undiagnosed impaired fasting glucose, impaired glucose tolerance, and gestational diabetes, she says.

The problem is compounded by the fact that the prevalence of the disease is increasing at a rapid pace, she adds.

In 1994, there were 99 million people worldwide with diabetes. That figure is expected to rise to an estimated 215 million by 2010.

However, there is a solution to the problem, she adds.

A three-year study of a comprehensive care program showed that diabetics who were closely monitored achieved a 26% decrease in inpatient days along with a 10% decrease in length of stay. Specialty visits decreased by 25% while pharmacy costs increased by 16% due to increase use of medications. Overall, the program achieved an 11% decrease in costs, Zazworsky says.1

An effective chronic care program takes a proactive, rather than a reactive approach to care, Zazworsky points out.

To develop a chronic care model in your organization, start by looking at the population you serve to determine how to design the program, Zazworsky advises.

Look at the diagnoses of your patients, how you treat the disease, and how you manage complications. Follow the disease process to the acute care episode and back, and look at ways to minimize the progression of the disease, she says.

"We need to develop ways to assess patients to identify those with no disease who are at risk and if they do have a disease to look at what kind of interventions they need," she says.

Examine how the organization of health care is established within your hospital, health system, or health plan. Look at the goals, incentives for providers, process improvements, and strong senior leadership support.

Look at effective programs in the community as well as within your organization, she suggests.

Research the resources available within your community including non-profit organizations, health plans, and governmental agencies such as local health departments.

Develop agreements that facilitate care coordination within and across organizations in your community, she adds.

Create formal partnerships among organizations in the community so you clearly understand what your relationship will be. Come up with a contact person at the agency.

Compile a list of community resources that can be used to help patients find resources that can help them manage their diseases, she says.

For instance, the St. Elizabeth Health Center created a list of agencies that offer walking and exercise programs as well as places where patients could go for low-cost diabetes supplies.

Within the delivery system, look at the roles of the team. Do you have planned visits to deal with chronic illness? How do you continue the care, handing off the patients from the hospital system to other providers in the community?

Look at each cost component of the program and determine what costs may be a barrier to patients. Look at the barriers to people in your community receiving care, she says.

"You need as an organization to determine how you can influence the cost of care for the uninsured," she says.

An effective chronic care program needs a clinical information system that maintains comprehensive information about patients, their conditions, and their adherence, she says.

For instance, you should be able to pull up a subgroup of patients with diabetes and a co-morbidity of congestive heart failure who are female and age 40 and older.

You should track how often the patients are hospitalized or visit the emergency department and whether they are filling their prescriptions or having the recommended tests and procedures.

[For more information, contact Donna Zazworsky, RN, MS, CCM, FAAN, manager of network diabetes care, faith community nursing and telemedicine for Carondelet Health Network in Tucson, AZ. E-mail:]


1. The New Economics of Diabetes Management, presented at the 60th Scientific Session of the American Diabetes Association, June 20, 2000.