Community-Based Partnerships for Improving Chronic Disease Management

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The expanded chronic care model

From a health care system perspective, the CCM, as developed originally by Wagner,2 identifies the essential elements that encourage high-quality care for individuals suffering from chronic disease. These elements are the health system, self-management support, delivery system design, decision support, clinical information systems, and individuals’ communities. This model was later refined to incorporate more specific concepts in each of those 6 elements—patient safety in health systems,

Realigning the patient-physician relationship

Because chronic disease management is complex, it also requires a new view of the patient-provider relationship in addition to enhanced community-based partnerships. Collaborative care is a partnership paradigm that credits patients with an expertise that is similar in importance to the expertise of professionals.4

According to Holman and Loring, 5 health care can be delivered more effectively and efficiently if patients are full partners in the process. When acute disease was the primary cause

Rationale for community partnerships in chronic disease management

Chronic conditions are rooted not only in physiologic processes but also in sociocultural and political contexts. Medical providers and programs, however, primarily consider chronic conditions at the individual or intrapersonal level. Chronic conditions are difficult to manage, much less cure, through a series of disconnected interventions, such as brief office visits, public health announcements, government funded programs, individual service programs, or the establishment of community

Social ecology theory and community partnerships

The Social Ecology Model7 of health promotion provides an important framework for integrating community partnerships and chronic disease management. According to social ecology theory, the potential to change individual risk behavior is considered within the social and cultural context in which it occurs.8 The Social Ecology Model describes several levels of influence that are critically interrelated and that must be recognized and addressed to effect positive health change, including

Community engagement and community capacity building

According to the Centers for Disease Control and Prevention (CDC),10 community engagement is defined as the process of working collaboratively with groups of people who are affiliated by geographic proximity, special interests, or similar situations with respect to issues affecting their well-being. It is helpful to consider the concepts of community and capacity building to help shape the community engagement process. First, the term, community, is a complex and fluid concept that needs to be

Thomas Jefferson University Department of Family and Community Medicine and Jefferson Center for Urban Health

The Thomas Jefferson University (TJU) Department of Family and Community Medicine (DFCM) is focusing on delivering a new model of care that provides state-of-the-art, comprehensive primary care in a variety of settings, from community to hospital, and engages communities in improving health indices. This new model of care, built on DFCM and TJU Hospitals (TJUH) resources and well-established links to community partnerships, integrates the best of family medicine, community, and public health

Summary

With the growing burden of chronic disease, the medical and public health communities are re-examining their roles and exploring opportunities for more effective prevention and clinical interventions. There is growing recognition of the need to address the underlying root causes/contributing factors that cross multiple chronic diseases and to integrate the silos in which chronic diseases are addressed. A social ecology approach to chronic disease calls for the development of new collaborations

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  • Cited by (25)

    • Clinic and Community: The Road to Integration

      2016, American Journal of Preventive Medicine
      Citation Excerpt :

      This level of integration would require commitment to a shared vision, a secure partnership, and an established process of support and communication. The prevention and chronic care communities have proposed frameworks for how to build such integration.11–21 The well-established Chronic Care Model17 presents a model of quality improvement that recognizes the role of the broader community, healthcare providers, and patients in improving chronic disease management.

    • Chronic disease management: Improving care for people with osteoarthritis

      2014, Best Practice and Research: Clinical Rheumatology
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      The question remains: is there, or indeed will there be, ideal models for the management of OA? The changes in broad CDM frameworks indicate that there is an increasing trend away from ‘disease’-oriented models to integrated community-based models (such as that developed by the World Health Organization) that integrate management issues between macro-, meso- and micro-levels of the health system and include a stronger public health preventative component and the expanded chronic care model that focusses on strengthening community partnerships [63]. Such an approach is supported by evidence that a strong primary health-care sector improves individual and population health outcomes [64].

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    The authors have nothing to disclose.

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