Addressing Chronic Disease

According to the Population Health course text, “Roughly 40 million Americans are still uninsured and 112 million Americans (almost half of the U.S. population, 45%) suffer from at least one chronic condition” in the United States, an estimated 125 million persons have at least one chronic condition, and half of these persons have multiple chronic conditions” (Fabius, and Pracilio, Nash, Clark, 2015, p. 4 ).

This week’s Learning Resources examine numerous health problems that result in a need for ongoing care. As you have explored this week, many costs are associated with chronic disease—both in terms of lives lost and socioeconomic burden. What can be done to help reduce chronic disease at the population level?

For this Discussion, you will take an in-depth look at chronic disease, and you will evaluate ways to address this issue through the application of chronic disease models and frameworks. In addition, you will consider the impact of the challenges of managing chronic disease on quality of care delivery.

To prepare:

  • Review      the application of chronic disease models as a method for managing chronic      diseases at the population level.
  • Consider      characteristics of chronic disease models and how to apply them as      presented in the Learning Resources.
  • Consult      Figure 13–7 (p. 267) in Population Health: Creating a Culture of      Wellness and consider examples of determinants and outcomes of      population health with chronic diseases in a specific subpopulation. Then,      select one chronic disease on which to focus for this Discussion.
  • Ask      yourself, “What are the challenges of managing this chronic disease? How      do these challenges limit the ability to deliver effective quality care?”      Conduct additional research using the Walden Library and credible websites      as necessary.

By tomorrow 05/01/2018 3 pm, write a minimum of 550 words in APA format with at least 3 scholarly references from the list of required readings below. Include the level one headings as numbered below”

Post a cohesive scholarly response that addresses the following:

1) Identify your selected chronic disease (refer to attached article).

2) Describe the application of a chronic disease model to address this disease at the population level (refer to attached article). Include your rationale for selecting this particular model.

3) Discuss one or more current challenges related to the management of the chronic disease and explain how these challenges limit the ability to deliver effective quality care.

Required Readings

Nash, D. B., Fabius, R. J., Skoufalos, A., Clarke, J. L. & Horowitz, M. R. (2016). Population health: Creating a culture of wellness (2nd ed). Burlington, MA: Jones & Bartlett Learning.

Chapter 10, “Transitions of Care”

Chapter 10 provides a framework for understanding the challenges faced by the U.S. health care system, including the shift from acute care to chronic care and the costs associated with that shift. Emerging models of chronic care delivery are presented.

Chapter 11, “Healthcare Quality and Safety Across the Care Continuum”

Chapter 11 examines the implications for quality and safety, and the imperative to focus on these issues at the population level under the mandate of the Affordable Care Act. The Examples of population-based quality and safety initiatives are presented.

Chapter 14, “Population Health in Action: Successful Models”

Chapter 14 focuses on improvements within population health, including chronic care. The Chronic Care Model, a conceptual framework, is discussed as a method for distributing care improvement to numerous practice settings. The key characteristics of a successful chronic care model that provide access to board populations are discussed.

Easley, C., Petersen, R., & Holmes, M. (2010). The health and economic burden of chronic diseases in North Carolina. North Carolina Medical Journal, 71(1), 92–95.

This short reading presents an analysis of the economic effects of selected chronic diseases resulting in increased hospitalization, with a focus on behaviors that may be changed to prevent these diseases.

Kim, T. W., Saitz, R., Cheng, D. M., Winter, M. R., Witas, J., & Samet, J. H. (2011). Initiation and engagement in chronic disease management care for substance dependence. Drug & Alcohol Dependence, 115(1–2), 80–86.

This article presents a study on treating substance abuse as a chronic disease. The authors discuss challenges to treatment options and propose methods for more appropriately managing treatment for substance dependence as a chronic illness.

Ormond, B. A., Spillman, B. C., Waidmann, T. A., Caswell, K. J., & Tereshchenko, B. (2011). Potential national and state medical care savings from primary disease prevention. American Journal of Public Health, 101(1), 157–164.

In this article, the authors examine whether population-based primary prevention activities lead to reduced disease onset in the short run, and, consequently, to cost savings within the health care system at both the state and national levels.

Tenforde, M., Jain, A., & Hickner, J. (2011). The value of personal health records for chronic disease management: What do we know? Family Medicine, 43(5), 351–354.

This reading examines evidence related to the value of electronic personal health records (PHRs), noting that additional research is needed to evaluate this for chronic disease management.

United Nations. (2011, September 19). Non-communicable diseases deemed development challenge of ‘epidemic proportions’ in political declaration adopted during landmark general assembly summit. Retrieved from

The United Nations met in September 2011 to collaborate on global plans to address the control and prevention of chronic diseases. This report from the general assembly notes the high cost of not managing chronic disease worldwide.

Yale School of Public Health. (2012). Chronic disease epidemiology. Retrieved from

Yale School of Public Health sponsors this site. Explore the information presented on addressing chronic disease through epidemiology.

Florida Department of Health. (n.d.). Bureause of epidemiology: Surveillance and investigation guidance. Retrieved March 5, 2012, from

This Florida-based agency monitors chronic disease conditions in Florida’s population using a variety of population-based surveillance systems.

World Health Organization. (2012). Chronic diseases and health promotion: Integrated chronic disease prevention and control. Retrieved from

The World Health Organization monitors chronic diseases worldwide. This website provides an overview of their programs, monitoring efforts, and activities they engage in to reduce the incidence of chronic disease globally.

Global Journal of Health Science; Vol. 7, No. 2; 2015
ISSN 1916-9736 E-ISSN 1916-9744

Published by Canadian Center of Science and Education


An Overview of Chronic Disease Models: A Systematic Literature

Ashoo Grover1 & Ashish Joshi2
1 Indian Council of Medical Research, Government of India, New Delhi, India
2 Center for Global Health and Development, College of Public Health, University of Nebraska Medical Center,
Omaha, Nebraska, USA
Correspondence: Ashish Joshi M.D., PhD, MPH, Assistant Professor, Center for Global Health and Development,
College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA. Tel: 1-402-559-2327, Fax:
1-402-559-2330. E-mail: [email protected]

Received: March 13, 2014 Accepted: August 18, 2014 Online Published: October 28, 2014
doi:10.5539/gjhs.v7n2p210 URL:

Aims: The objective of our study was to examine various existing chronic disease models, their elements and
their role in the management of Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Cardiovascular
diseases (CVD).
Methods: A literature search was performed using PubMed and CINHAL during a period of January 2003-
March 2011. Following key terms were used either in single or in combination such as “Chronic Disease Model”
AND “Diabetes Mellitus” OR “COPD” OR ‘CVD”.
Results: A total of 23 studies were included in the final analysis. Majority of the studies were US-based. Five
chronic disease models included Chronic Care Model (CCM), Improving Chronic Illness Care (ICIC), and
Innovative Care for Chronic Conditions (ICCC), Stanford Model (SM) and Community based Transition Model
(CBTM). CCM was the most studied model. Elements studied included delivery system design and
self-management support (87%), clinical information system and decision support (57%) and health system
organization (52%). Elements including center care on the patient and family (13%), patient safety (4%),
community policies (4%), built integrated health care (4%) and remote patient monitoring (4%) have not been
well studied. Other elements including support paradigm shift, manage political environment, align sectoral
policies for health, use healthcare personnel more effectively, support patients in their communities, emphasize
prevention, identify patient specific concerns related to the transition process, and health literacy between visits
and treatments have also not been well studied in the existing literature.
Conclusions: It was unclear to what extent the results generated is applicable to different populations and
locations and therefore is an area of future research. Future studies are also needed to test chronic disease models
in settings where