According to Australian Primary Health Care Research Institute report (2006), the World Health Organization defines chronic diseases as those diseases that have at least one of the following characteristics;
- Being permanent
- Their cause is non-reversible pathological alteration
- Leave behind residual disability
- The patient having any of these diseases need special training for rehabilitation or this patient may need long-term supervision or care.
Considering the case of Australia, the Australian Institute of Health and Welfare made a list of 12 diseases that had the biggest impact on the health care system of this nation. The diseases listed included “coronary heart disease, stroke, lung cancer, depression, chronic kidney disease, oral diseases, colorectal cancer, diabetes, asthma, arthritis, chronic obstructive pulmonary disease and osteoporosis” (Australian Institute of Health and Welfare (AIHW). 2001). On an increasing level, those people having chronic diseases are being taken care of in primary care and this care is being given out by the general practitioners who are also assisted by other professionals in primary health care. These people have been working under joint arrangements with specialized services (Australian Primary Health Care Research Institute report, 2006).
The BEACH report (Bettering the Evaluation and Care of Health) tried to trace out those chronic diseases which are managed in primary care more often. According to the report, the diseases included; “hypertension, coronary heart disease, depression, diabetes, lipid disorders, chronic pulmonary disease, arthritis and osteoporosis” (Britt, et al., 2004). Other chronic diseases such as lung cancer as well as colorectal cancer are significant but their management is not carried out in primary care frequently and therefore these diseases do not make a large contribution to the overall burden brought in by the chronic diseases as it is looked at in this context. This paper is going to look at chronic diseases in the context of Australia and also in the Saudi Arabian context. Comparison and contrast are going to be carried out in these two nations in regard to the management of chronic diseases. This is going to be carried out based on two models; ICCC and CCM. These two models are also going to be looked at in the paper to have a clear understanding of them
Rationale for considering chronic diseases
Chronic diseases bring in a big challenge to the health and social systems of any country. Taking the case of Australia, chronic diseases currently make a contribution of more than 70 percent of the disease burden and this percentage is projected to rise even higher to about 80 percent come the year 2020 (National Health Priority Action Council, 2006). To deal with this issue, the government of Australia has taken an initiative to put much focus on the prevention of the chronic diseases and managing these diseases and this has been carried out through three main policies which are; the National Chronic Disease Strategy, National Service Improvement Framework, and the Blueprint for Chronic Disease Surveillance” (National Health Priority Action Council, 2006). To offer support to this, the Australian government has raised the level of funding for chronic disease self-management programs which are delivered by the primary health services across the nation. According to Somers, Guerin, Luker, Jones and Zucco (2009: 2), “the priority CDs or chronic diseases outlined under the National Service Improvement Framework are asthma, cancer, diabetes, heart disease, stroke and vascular disease, osteoarthritis, rheumatoid arthritis, and osteoporosis”.
Taking the case of Saudi Arabia, according to the World Health Organization report (2003), the deaths that resulted from chronic diseases accounted for 69 percent of the total deaths. World Health Organization (2003) report points out that “at least 80 percent of premature heart disease, stroke and type 2 diabetes and 40 percent of cancer could be prevented through health diet, regular physical activity and avoidance of tobacco products”. The interventions to this that are cost effective are there and these interventions have been effective in several countries around the world (Renders, et al, 2000). The strategies by which much success has been attained have utilized various population wide moves worked together with intervention for individual people (Warsi, LaValley, Wang PS, Avorn, and Solomon,2003).
Chronic Disease Management Models
According to Weingarten et al (2002), the definition for chronic disease management is stated as an intervention devised to enable the prevention or management of a chronic condition by employing an approach that is systematic to care and prospectively using multiple treatment modalities.
Australian Primary Health Care Research Institute (2006) report points out that “in Australia and other comparable countries there has been a shift in health care from a reactive system with a focus on acute care to one that is proactive, which supports the management of chronic diseases.” Various policy and system changes to deal with the issue of chronic disease management have been there. There are two chronic disease management models; Innovative Care for Chronic Condition Model (ICCC) and Chronic Care Model (CCM).
Innovative Care for Chronic Conditions (ICCC)
According to Australian Primary Health Care Research Institute (2006) report, in the recent times, a report was published by the World Health Organization and this move served as a response to the increase in the prevalence of various chronic diseases in the whole world (World Health Organization., 2002). The main objective of this report (ICCC) was to describe an all-inclusive world framework for preventing and controlling the chronic diseases and this could apply to developed countries as well as developing nations. This report pointed out that in most of the nations in the world, health care systems have been built up to handle “acute episodic care”, and this is not suitable for managing and controlling chronic conditions over a long period of time or in the long run.
Eight elements were identified by the World Health Organization which are vital for the attainment of success in carrying out chronic disease management in whatever the health care system. The first element that was identified is to have support for a model change to a more suitable system from acute care to meet the needs of those people having chronic diseases or conditions. The second element presented is to carry out effective management of the political environment to make sure there is commitment at all levels having to share of the information. The third one is that there should be building up healthcare that is integrated to make sure there is sharing of information among the services and providers at all times. The fourth element is to ensure alignment of the policies of the sectors and not just with health but in an all-inclusive manner in all other areas which includes the workforce and education among other areas.
The fifth one is to have effective utilization of the personnel in health care and this is with the intention of maximizing the roles played by all those parties that are engaged in taking care of the patients and making recognition of the significance of the roles of these people or parties in carrying out the management of the chronic diseases. The sixth element is to focus care on the chronic disease patients as well as their families having a change from the patient as an inactive receiver of care to a situation or model in which the patient has to take some level of responsibility for that care that has to be given him or her. The second last element is to offer support to the patients within the communities to which they belong with those programs that run the organizations that deal in health care and the community at large. The last element is to put much emphasis on prevention.
The discussion of health care systems organization is carried out at three levels; Macro, intermediate and micro levels and the way they contribute to the carrying out the management of the chronic conditions. In considering the macro level, the governments of nations are supposed to have policy to be used in realizing prevention and management of chronic conditions. This encompasses high as well as low technology approaches having the evasion of financing that is fragmented and the motivation schemes that are not aligned; having neither regulation nor monitoring of the standards.
In considering the intermediate or meso level, at this particular level, systems are supposed to be put in place to carry out the management of care over a period of time contrary to acute episodic care. In this, there will be involvement in educating the professionals in health care sector, giving guidelines that are based on evidence, offering strategies for prevention, putting in place information systems and having connection with community resources. At micro level, there is need for the development of skills among individuals for them to prevent and carry out management of their health.
In setting up the ICCC, the World Health organization copied from the CCM – Chronic Care Model which was developed by Wagner together with other people with whom he worked. This model was expanded to use it particularly in the developing nations (Wagner, Austin, and Von Korff, 1996)
Chronic Care Model
The development of this model was carried out in the United States of America and this was carried out after carrying out an extensive literature review. This model is the commonly known care model for those people having chronic diseases (Wagner, Austin and Von Korff, 1996).
This model describes those elements that are vital for realizing improvement in people’s cars that are having chronic diseases with main concentration lying in primary care. The general objective of this model is to build up the patients that are well-informed and also build up a health care system that is put in place for these people. This model has six elements and these elements include; the first one is Delivery System Design (DSD). This is a structure of the medical practice put in place to come up with teams having a division of labour that is clear giving a separation between planned care and the acute care. The next is Self Management Support or SMS. Under this, there is assisting of the patients collaboratively together with offering assistance to their families to obtain the skills and confidence which is essential in managing their condition.
Another element is Decision Support or DS. There is integration of clinical guidelines that are based on evidence in to the reminder systems as well as practice systems. These are guidelines that have been reinforced by the clinical champions that are offering education to other professionals in the health care sector. The other element is CIS or Clinical Information Systems. The main roles played by the computer information systems include reminder system that is utilized in the improvement in compliance with the set guidelines, performance measure feedback and the last important role is registries care planning for decision support. The second last element is Community Resources or CR. Here the connections with those hospitals that are offering patient education or agencies for home care to offer care managers are looked at. The last element is Health Care Organization or HCO. This refers to the structure of the provider organization as well as its goals and values. According to Bodenheimer, Wagner and Grumbach (2002 [a]), “its relationship with purchaser, insurers, and other providers underpins the model”.
All the six elements of this model work in a triangle; the community, the system of health care and the provider organization. This model permits division of labor and also allows for a shift to long term care from acute care. According to Bodenheimer, Wagner, Grumbach ( 2002 [b]), attempts have been made to carry out the assessment of the CCM impact on the chronic condition outcomes and to seek to carry out the determination of the level to which the elements of this model have made a contribution to care. The observations from this suggest that including at least one or more elements of the model brought about the outcomes of the patient or the outcomes of the process for various chronic conditions. There has been no testing of the CCM in its totality but there has been incorporation of the elements of this model in to chronic disease management and policy programs in various nations.
Chronic Disease Management in Australia and Saudi Arabia
Focus has also been put on the element of self management of CCM via commonwealth program that puts focus on chronic disease self management. 12 demonstration projects of chronic disease self management were funded by “Sharing Health Care Initiative 1999 – 2007”. These projects dealt with various chronic conditions and essentially involved offering education as well as training to the patients and also to the health care professionals. The education programs for self management that were employed encompassed the Finder’s Model (Battersby and the SA HealthPlus Team, 2005) and the Stanford Model (Lorig, Sobel, Stewart, Brown, Bandura, Ritter, et al., 1999)
More so, the Australian government has taken some initiatives to prevent chronic diseases. This government came up with what is referred to as SNAP- Smoking, Nutrition, Alcohol and Physical Activity framework and this was in response to evidence that was established that there can be implementation of modification in lifestyle in general practice but also that few encounters involve risk factor assessment in relative terms (Australian Government Department of Health and Ageing. Smoking, Nutrition, Alcohol, Physical Activity (SNAP), 2005)
In the most recent times, the government of Australia has announced the ABHI- Australian Better Health Initiative which is a package that lasts for five years geared towards bringing down the level of the chronic disease impact. The package encompasses a Medicare Benefits Schedule item for a health check which is focused to be accessible through general practice for those individuals who are about forty five years of age among which there is identification of some risk factors that may bring about chronic disease (Powell and Gibson, 2002). This package as well encompasses some initiatives put in place to offer support to change in lifestyle among people through educating individuals as well as groups. These measures that form part of ABHL go in line with the CCM elements of support for self management as well as delivery system design.
There has been need for higher consistency as well as linkages policy approaches as well as program approaches at the state levels as well as common-wealth level when considering the key issue with the approaches to this day to bring in improvement in the management of the chronic diseases in Australia for the whole population at macro level. According to Australian Primary Health Care Research Institute report (2006). “There have been policy work to better define and coordinate Australia’s chronic disease policy framework through the development of the National Chronic Disease Strategy (NCDS) which seeks to provide an overarching policy framework for action on chronic disease.” The National Chronic Disease Strategy do not have strategy for implementation and there are expectations that these need to be individual jurisdictions’ responsibility (Australian Primary Health Care Research Institute (2006).
In looking at the case of Saudi Arabia, according to Amustafa (2002), there has been poor management in the primary health care in Saudi Arabia. In relating this to chronic diseases, those programs that are aimed to deal with chronic conditions have been below target (Al-Khaldi and Al-Sharif., 2002). Considering a chronic disease like hypertension, the low rates of referrals have prevented suitable access to the care by specialists (Taylor, Candy, Bryar, Ramsay Vrijhoef, Esmond G, et al.2005). According to Al Khaldi, Al-Ghorabi, Al-Asiri and Khan (2002), access by the people to health education is established to be quite minimal and there is poor information access which brings in hardships in making independent decisions.
According to Almustafa, et al (2006) taking the Chronic Care Model in to account, the existing guidelines that are put in place do not meet the Chronic Care Model (CCM) needs. To realize improvement in dealing with chronic conditions in this country, Amustafa suggests a CMR management guideline. The existing guidelines are not tailored for Primary Health care and they are very difficult to follow. What is seen to be special in the suggested guideline is that it is patient –oriented, and has proven provider behavior change methods. The guideline has also various self-management tools. The guideline is also made by PCP for primary care. More so, of importance still, the guideline has been designed in such a way that there are various flow charts and these charts give guidance to the process of decision making.
In the discussion above, chronic diseases have been looked at in the context of Australia and Saudi Arabia. It has been established that there is great need to carry out the management of the chronic diseases by adopting the appropriate models in carrying out this In comparing Australia and Saudi Arabia in relation to the moves that have been taken to deal with the problem of the chronic diseases in these countries; it is realized that much has been done in Australia as compared to Saudi Arabia.
The steps that have been taken in Australia are in line with the elements of the Chronic Care Model. This is not the case with Saudi Arabia. The guidelines that have been put in place to deal with the chronic diseases such as hypertension are not effective and do not go in line with the4 CCM elements. However, there is a move to put in place a new guideline that is going to play a major role in realizing effective chronic disease management.
Each and every nation in the whole world needs to take appropriate steps to deal with chronic conditions. These conditions are established to be very serious and pose a great danger to human life and development of the nations at large. There is need to adopt the elements of the ICCC model as we as the Chronic Care Model to ensure there is success in dealing with chronic conditions by both developing and developed nations.
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