Coordinating care across chronic diseases – What is the way ahead?

By Laura Cigolot

“If we want to keep people healthy for as long as possible we need to focus on 3 Ps:

Prevention, promotion and protection. Promoting good health – through healthy eating, exercise, healthy living and working conditions; Protecting citizens – by ensuring safety at work, on roads, or elsewhere; and Preventing disease – tackling all the risk factors

Vytenis Andriukaitis, European Commissioner for Health and Food Safety, 21 April 2016

Over time, noncommunicable diseases (NCDs), simply known as chronic diseases, have been elevated onto national and worldwide health and development agendas, ringing the bell for urgent actions and solutions.

Chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are the leading cause of mortality and morbidity in Europe, representing 77% of the total disease burden and 86% of all deaths. In accordance with the definition of the World Health Organization (WHO), such diseases are diseases of long duration and generally slow progression.

In the past, chronic diseases were perceived to be a concern of the rich and elderly population. Today, in Europe, they lead to the premature death of more than 550,000 people aged 25 to 64 each year, resulting in the loss of some 3.4 million potential productive life years.

Chronic diseases also bring significant outcomes. In fact, they lower salaries, takings, workforce participation and labour productivity, as well as increase early retirement, high job turnover and disability. Approximately €700 billion is spent every year across Europe on the treatment of these diseases. Research warns us that complex conditions, such as diabetes and depression, will impose an even larger burden in the coming years.

Therefore, which strategies can be adopted for tackling chronic diseases?

The burden of noncommunicable diseases points out the need of new solutions and interventions as key tools to successfully curb the growth and advancement of such conditions, and to develop relative treatment plans.

The European Parliament resolution on Non-Communicable Diseases (NCDs) of 15 September 2012 highlights the importance of the early identification of individuals who are at high risk of contracting or dying from these diseases or are suffering from pre-existing dispositions, chronic and severe illnesses and risk factors that aggravate NCDs. In line with this, the majority of EU countries are experimenting with disease prevention and early detection.

Prevention is the most effective, affordable way to reduce risk and severity of such diseases. Advancing quality preventive services in both clinical and community settings, empowering people to make healthy choices and ending social and educational inequalities are crucial pillars we need to endorse in the prevention process of chronic conditions. In addition to this, early detection and diagnosis along with implementation of screening and disease management programmes represent effective measures that can be taken to face the challenges of an ageing population and the emergence and acute phase of chronic diseases, saving hundreds of thousands of lives and billions of euros. Timely diagnosis appears crucial. It can help people diagnose the disease while it is asymptomatic, with no signs or symptoms, thus improving possibilities to identify the onset of a disease. Secondly, the earlier detection of disease may impact the progression of major chronic diseases, leading to more cures or longer survival and offering time saving measures.

Managing chronic diseases through Integrated Care frameworks

It is also the area of chronic disease where the greatest advantage lies in developing integrated care models, aimed at improving coordination within the entire care process, building on scientific evidence and patient involvement.

In March 2017, the Expert group on Health Systems Performance Assessment (HSPA) has provided a relevant report to assess integrated care in Europe, aimed at enhancing patient-centred care tailored to individual needs and which allows them to be involved in their own care.

Demographic changes have resulted in people living longer but also in the broad diffusion of chronic long-standing illnesses. Therefore, it is of central importance to reflect on this and encourage the transition towards a framework of integrated care within and beyond Europe.

It is about incorporating patient care across the continuum of care. The term patient does not imply an abstract, distant concept. It is about us, our health status and quality of life.

It is about combining an horizontal integration with a vertical integrationreflecting on the complexity of our system, and bringing together (integrating) political support, stakeholders’ engagement and patients’ empowerment.

The concept of integrated care is a valuable tool for moving forward towards a concrete paradigm shift in our health systems. A changeover that will redefine the relationship between different providers of treatment, being respectful of, and responsive to, individual patient preferences, demands and values.

We all know that chronic diseases cannot be treated in isolation. Consequently, a vast majority of the population with complex care needs calls for the development of care delivery systems that unite a range of professionals and expertise from the healthcare, long-term and social care domains. New models of integrated care can organize treatment (and prevention) in a way that services are better integrated across the whole range of care.

Despite some valuable instances in Europe, such as the introduction of case management by the National Health Service (NHS) in the United Kingdom, and the creation of pilot projects in several Spanish autonomous communes, the effectiveness of integrated care models has been quite controversial due to the absence of definite conclusions of some large-scale population-based studies. Given the complexity of integrated care, implementation represents a key challenge. New studies are thus required on implementation issues providing more evidence on cost−effectiveness.

The healthcare system can only benefit from the design and application of innovative integrated care frameworks. In this frame, more commitment from policymakers, researchers and different stakeholders is needed to promote a clear line of accountability and continuity of staff among professionals, and to enhance the full integration of disciplines along with a very high level of transparency that supports patients’ choices through appropriate financing and payment schemes. Inter-sectoral co-ordination is at the core of the matter, while establishing strong governance mechanisms at all levels and setting up organisational changes in terms of healthcare settings, organisation of workflows, workforce development and resource allocation.

Coordinating efforts, skills and provider networks will be vital to facilitate and accomplish the transition toward a new ecosystem, where all patients will be members of the “care team”, and which will increase the effectiveness of the system at all levels, enhancing innovation, reducing costs and improving patient safety for a healthier community. It is worth remembering that health is our greatest wealth.