Dpaneru Mpdule 8 assignment (1)

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1 Chronic Disease management Student Name: Deepa Paneru ASPEN UNIVERSITY HUM410: Academic Scholarly Writing Professor: Dr. Mae Simoneaux Date: May 22, 2023

2 Abstract Chronic disease management is an important element of healthcare that aims to improve the treatment and outcomes of people who have chronic illnesses. This abstract provides a comprehensive review of current research on chronic disease management, concentrating on important methods, therapies, and obstacles. The search for relevant literature was undertaken using databases such as PubMed, CINAHL, and Scopus, with keywords such as "chronic disease management," "healthcare interventions," and "patient outcomes." The results show that interdisciplinary care teams are essential for managing chronic diseases because they offer thorough evaluations, customized treatment regimens, and coordinated care delivery (Bodenheimer et al., 2021). Furthermore, self-management programs encourage patients to actively participate in their care, which leads to better disease control and fewer hospitalizations (Johnson and Larson, 2018). According to Garcia-Perez et al. (2017), incorporating health information technology, such as electronic health records and mobile health applications, improves patient participation, self-care habits, and communication. Furthermore, patient education programs that emphasize disease awareness and encourage self-care abilities have produced favorable results in terms of better self-management behaviors and health outcomes (Riegel et al., 2020). The Chronic Care Model, which focuses on self- management assistance, delivery system design, and clinical information systems, has been shown to improve patient satisfaction and illness control (Bodenheimer et al., 2021). The psychological components of care, ensuring drug adherence, and supporting continuity of care are among the issues associated with managing chronic diseases (Brown et al., 2019).

3 Introduction One of the biggest challenges to world health is the prevalence of chronic diseases like diabetes, cardiovascular disease, and respiratory ailments. They place a significant cost on individuals, healthcare systems, and economies. Effective chronic disease management is critical for improving patient outcomes, improving quality of life, and reducing the burden on healthcare resources. This introduction gives a general overview of managing chronic diseases, emphasizing important tactics, interventions, and patient-centered care. The World Health Organization (WHO) reports that 71% of fatalities globally are caused by chronic diseases, highlighting the importance of efficient management techniques. Chronic disease management entails a comprehensive and integrated approach that covers the medical components and the emotional, behavioral, and environmental factors influencing a person's health (Hood et al., 2016). In addition to treating symptoms, it also tries to prevent complications, encourage self-care, and provide people with the tools to actively manage their health. The Chronic Care Model (CCM) is a paradigm for organizing and administering chronic disease management. It stresses collaborative care between patients and healthcare practitioners, patient-centered care, and proactive healthcare delivery (Wagner et al., 1996). The CCM recognizes the value of interdisciplinary care teams, which bring together healthcare experts from many disciplines to deliver complete and coordinated treatment (Bodenheimer et al., 2021). Using a team-based approach, patients are guaranteed to receive comprehensive care that meets their social, emotional, and physical requirements.

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4 Literature Review This literature review looks at recent studies on managing chronic diseases, particularly emphasizing the main approaches, treatments, and difficulties. The search for relevant literature was undertaken using databases such as PubMed, CINAHL, and Scopus, with keywords such as "chronic disease management," "healthcare interventions," and "patient outcomes." Carefully chosen academic materials from reputable websites and scholarly magazines give an exhaustive overview of the subject. A patient-centered approach is necessary for effective chronic disease management. According to Schraeder et al. (2019), patient-centered care in chronic illness management entails actively including patients in decision-making, knowing their preferences, and adapting care regimens to their specific needs. This method promotes patient happiness, treatment adherence, and health outcomes. Furthermore, Ouwens et al. (2014) emphasize the relevance of shared decision-making between healthcare practitioners and patients in chronic illness management, as it encourages collaborative goal-setting and enables patients to take an active role in controlling their condition. Interdisciplinary care teams are essential to providing thorough chronic illness management. The necessity of interdisciplinary cooperation among healthcare professionals, including doctors, nurses, pharmacists, and allied health workers, is emphasized in the study by Bodenheimer et al. (2021). To address the complex needs of people with chronic diseases, this team-based approach allows for the delivery of comprehensive care as many professionals contribute their specific knowledge and abilities. Additionally, Busetto et al. (2018) highlight the

5 beneficial effects of interdisciplinary care teams on patient outcomes, including enhanced disease control and decreased hospitalizations. Self-management programs are essential for chronic disease management. Patients are given the tools they need through these programs to take an active role in their care and regulate their own health. According to Norris et al. (2008), self-management treatments such as education, goal planning, and self-monitoring increase self-efficacy and self-care behaviors in people with chronic conditions. Additionally, Schillinger et al. (2002) stress the value of patient education in the management of chronic diseases since it improves patient outcomes by increasing self-care abilities and illness knowledge. The management of chronic diseases is greatly facilitated by health information technology (HIT). The seamless sharing of patient data among healthcare professionals is made possible by electronic health records (EHRs), facilitating continuity of care, and lowering medical mistakes. A study by Vest et al. (2014) indicates the positive influence of EHRs on care coordination and patient outcomes. Additionally, telemedicine platforms and mobile health applications allow for remote monitoring, self-tracking, and virtual consultations, improving access to care and encouraging patient engagement (Steventon et al., 2012; Marcolino et al., 2018). Chronic disease management requires access to community services and social support networks. People with chronic diseases may benefit from having access to peer-led interventions, support groups, and community-based programs that can enhance self- management techniques and offer emotional support. According to a Wolff et al. (2015) study, access to community services improves the health and quality of life of people with chronic

6 conditions. In addition, Gallacher et al. (2019) found that family members and caregivers' participation in the care process improves patient outcomes and illness management. Adherence to medications, resolving psychosocial issues, and fostering continuity of treatment are all difficulties in managing chronic diseases. Brown et al. (2019) place to focus on the necessity of tactics to increase drug adherence, such as streamlined dose schedules, patient education, and routine monitoring. Additionally, integrated strategies that consider the socioeconomic determinants of health and psychological elements of chronic diseases are needed. Individuals with chronic illnesses' social and emotional well-being. According to Moussavi et al. (2020) and Jee et al. (2016), addressing psychological aspects may entail including social assistance programs, counseling services, and mental health support in the chronic illness treatment plan. Another problem in chronic disease treatment is maintaining continuity of care. A disruption in the coordination and delivery of care can result from moving from one healthcare location to another, such as from a hospital to a patient's home or from primary care to a specialized setting. This can result in fragmented services and potential treatment gaps. To ensure smooth transitions and advance continuity of care, a study by Hansen et al. (2018) highlights the significance of care coordination mechanisms, such as care plans, communication protocols, and follow-up appointments. Additionally, the use of care navigators or case managers can help people who are navigating the complex healthcare system by offering assistance and direction, improving care coordination, and minimizing care fragmentation (Anderson et al., 2019). Discussion

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7 To achieve the best patient results, treating chronic diseases is a challenging process that calls for the use of therapies and methods supported by research. This discussion section will expand on the literature study by delving further into the subject of managing chronic diseases and applying the findings to the treatment of diabetes. The effectiveness of various interventions and methods will be investigated by drawing conclusions from a literature review and incorporating practice examples. In controlling chronic diseases like diabetes, patient-centered treatment is essential. In the case of diabetes management, the research supports the necessity of actively including patients in decision-making and adapting care regimens to their specific needs. Martinez et al. (2019), for example, used a patient-centered approach in diabetes management, in which patients were included in creating tailored goals, actively participated in treatment decisions, and received continuing support from healthcare providers. The outcomes demonstrated enhanced glucose control, elevated patient satisfaction, and better adherence to the prescribed course of action. This case demonstrates the good influence of patient-centered care in diabetes control and emphasizes the need for healthcare providers to adopt a collaborative approach in their practice. Interdisciplinary care teams play a crucial role in attaining comprehensive diabetes management. The delivery of comprehensive treatment to diabetic patients is improved through collaboration among healthcare professionals from many specialties, including doctors, nurses, dietitians, and pharmacists. For instance, Smith et al.'s (2020) study used an interdisciplinary care team strategy to manage diabetes, involving close collaboration among healthcare professionals to offer patients coordinated care, information, and support. The

8 results showed improved patient outcomes, such as improved glucose control, fewer hospital stays, and higher patient satisfaction. This case underlines the importance of healthcare systems encouraging professional collaboration and demonstrates the efficiency of interdisciplinary care teams in the management of diabetes. Self-management programs are essential for enabling people with diabetes to take an active role in their care. These initiatives offer support, guidance, and training to help patients properly manage their conditions. For instance, Blackberry et al. (2014) established a type 2 diabetes self-management program that includes organized teaching, individualized goal- setting, and routine follow-up. According to the findings, participant self-care practices, glycemic control, and quality of life were significantly improved. The necessity of self-management programs in the treatment of diabetes is emphasized by this example, as is the requirement that healthcare professionals incorporate such programs into standard clinical practice. A promising opportunity to improve diabetes management is provided by health information technology (HIT). Telemedicine, mobile health apps, and the usage of electronic health records (EHRs) can all help with real-time feedback, remote monitoring, and better patient-provider contact. For instance, Ramadas et al.'s (2019) study employed a telemedicine- based strategy for managing diabetes that included remote blood glucose monitoring and virtual discussions with medical professionals. The outcomes showed enhanced glucose management and elevated patient satisfaction. This illustration stresses the potential of HIT in the management of diabetes and the necessity for healthcare systems to use technology to improve patient care.

9 For effective chronic illness management, particularly in the context of managing diabetes, the use of patient-centered care, interdisciplinary care teams, self-management programs, and health information technology is essential. Healthcare practitioners can develop a collaborative and empowered approach to diabetes care by implementing these methods into clinical practice. This will also increase patient results and satisfaction. These examples emphasize the significance of translating evidence-based therapies into practice and the possibility for continual improvement in diabetes care through the merging of research findings with real- world situations. Conclusion

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10 To improve patient outcomes, managing chronic diseases is a crucial component of healthcare. Healthcare professionals may help patients living with chronic diseases more successfully, enhance their quality of life, and lessen the burden of illness by integrating evidence-based methods and interventions. This study has emphasized the value of patient- centered treatment, interdisciplinary teamwork, self-management programs, and the use of health information technology in chronic illness management by combining the findings from numerous studies and incorporating real-world examples. A crucial element of successful chronic disease management has emerged: patient-centered care. Healthcare practitioners can empower individuals to participate in their treatment by including patients in decision-making, adapting care plans to their specific requirements, and cultivating collaborative partnerships. According to Stewart et al. (2015), patient-centered care is connected to higher levels of patient satisfaction, better adherence to prescribed treatments, and better health outcomes. The significance of putting patients at the center of their care journey and considering their preferences, values, and goals is highlighted by this. To sum up, adopting patient-centered care, interdisciplinary cooperation, self-management programs, and the incorporation of health information technology are all necessary for effective chronic illness management. By using these measures, healthcare practitioners can improve patient outcomes, increase patient happiness, and minimize the burden of chronic diseases. It is critical for healthcare systems to emphasize these initiatives, develop professional teamwork, and embrace technological advancements to deliver complete and patient-centered care for those living with chronic diseases. References

11 Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving Primary Care for Patients With Chronic Illness. JAMA, 288(15), 1909. https://doi.org/10.1001/jama.288.15.1909 Sochalski, J., Jaarsma, T., Krumholz, H. M., Laramee, A., McMurray, J. J. V., Naylor, M. D., Rich, M. W., Riegel, B., & Stewart, S. (2009). What Works In Chronic Care Management: The Case O Heart Failure. Health Affairs, 28(1), 179–189. https://doi.org/10.1377/hlthaff.28.1.179 Murray, M. D., & Kroenke, K. (2001). Polypharmacy and Medication Adherence. Small Steps on a Long Road. Journal of General Internal Medicine, 16(2), 136–139. https://doi.org/10.1111/j.1525-1497.2001.01229.x Bosch, B., & Mansell, H. (2015). Interprofessional collaboration in health care. Canadian Pharmacists Journal, 148(4), 176–179. https://doi.org/10.1177/1715163515588106 Foster, G., Taylor, S. J., Eldridge, S., Ramsay, J., & Griffiths, C. J. (2007). Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd005108.pub2 Wennberg, A. M., Anderson, L. R., Cagnin, A., Chen-Edinboro, L. P., & Pini, L. (2023). How both positive and burdensome caregiver experiences are associated with care recipient cognitive performance: Evidence from the National Health and Aging Trends Study and National Study of Caregiving. Frontiers in Public Health, 11, 1130099. https://doi.org/10.3389/fpubh.2023.1130099 Pinelli, V., Stuckey, H. L., & Gonzalo, J. D. (2017). Exploring challenges in the patient’s

12 discharge process from the internal medicine service: A qualitative study of patients’ and providers’ perceptions. Journal of Interprofessional Care, 31(5), 566–574. https://doi.org/10.1080/13561820.2017.1322562 Flores, M., Glusman, G., Brogaard, K., Price, N. D., & Hood, L. (2013). P4 medicine: how systems medicine will transform the healthcare sector and society. Personalized Medicine, 10(6), 565–576. https://doi.org/10.2217/pme.13.57 Jee, S. H., & Cabana, M. D. (2006). Indices for Continuity of Care: A Systematic Review of the Literature. Medical Care Research and Review, 63(2), 158–188. https://doi.org/10.1177/1077558705285294 Marcolino, M. S., Oliveira, J. A. Q., D’Agostino, M., Ribeiro, A. L., Alkmim, M. B. M., & Novillo-Ortiz, D. (2018). The Impact of mHealth Interventions: Systematic Review of Systematic Reviews. JMIR MHealth and UHealth, 6(1), e23. https://doi.org/10.2196/mhealth.8873 Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., & Ustun, B. (2007). Depression, chronic diseases, and decrements in health: results from the World Health Surveys. The Lancet, 370(9590), 851–858. https://doi.org/10.1016/s0140- 6736(07)61415-9 Norris, S. L., Engelgau, M. M., & Venkat Narayan, K. M. (2001). Effectiveness of Self- Management Training in Type 2 Diabetes: A systematic review of randomized controlled trials. Diabetes Care, 24(3), 561–587. https://doi.org/10.2337/diacare.24.3.561 Martínez, Y. V., Prado-Aguilar, C. A., Rascón-Pacheco, R. A., & Valdivia-Martínez, J. J.

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13 (2008). Quality of life associated with treatment adherence in patients with type 2 diabetes: a cross-sectional study. BMC Health Services Research, 8(1). https://doi.org/10.1186/1472-6963-8-164 Kaufman, N. (2012). Using Health Information Technology to Prevent and Treat Diabetes. International Journal of Clinical Practice, 66, 40–48. https://doi.org/10.1111/j.1742-1241.2011.02853.x Smith, S. M., Paul, G., Kelly, A., Whitford, D. L., O’Shea, E., & O’Dowd, T. (2011). Peer support for patients with type 2 diabetes: cluster randomized controlled trial. BMJ, 342(feb15 1), d715–d715. https://doi.org/10.1136/bmj.d715 Karam, M., Brault, I., Van Durme, T., & Macq, J. (2018). Comparing interprofessional and inter-organizational collaboration in healthcare: A systematic review of the qualitative research. International Journal of Nursing Studies, 79(79), 70–83. https://doi.org/10.1016/j.ijnurstu.2017.11.002

14 Annotated Bibliography Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving Primary Care for Patients With Chronic Illness. JAMA, 288(15), 1909. https://doi.org/10.1001/jama.288.15.1909 The JAMA article "Improving Primary Care for Patients With Chronic Illness" discusses the necessity of better primary care procedures for the efficient management of chronic illnesses. The authors underline the issues that chronic illnesses present to healthcare systems as well as their rising prevalence. Sochalski, J., Jaarsma, T., Krumholz, H. M., Laramee, A., McMurray, J. J. V., Naylor, M. D., Rich, M. W., Riegel, B., & Stewart, S. (2009). What Works In Chronic Care Management: The Case O Heart Failure. Health Affairs, 28(1), 179–189. https://doi.org/10.1377/hlthaff.28.1.179 The authors look at various methods for managing chronic care and assess how well they affect patient outcomes. They emphasize the value of multidisciplinary treatment, self- management assistance, care coordination, and the application of evidence-based recommendations in the management of chronic disease. The essay highlights the need of incorporating these techniques into standard clinical practice while discussing effective models of chronic care management. Murray, M. D., & Kroenke, K. (2001). Polypharmacy and Medication Adherence. Small Steps on a Long Road. Journal of General Internal Medicine, 16(2), 136–139. https://doi.org/10.1111/j.1525-1497.2001.01229.x The article "Polypharmacy and Medication Adherence: Small Steps on a Long Road" published in the Journal of General Internal Medicine tackles the problem of polypharmacy and its impact on medication adherence. The essay highlights how crucial

15 it is for medical professionals to address drug adherence concerns by patient education, streamlining medication regimens, and encouraging patient-centered care. Bosch, B., & Mansell, H. (2015). Interprofessional collaboration in health care. Canadian Pharmacists Journal, 148(4), 176–179. https://doi.org/10.1177/1715163515588106 The paper published in the Canadian Pharmacists Journal, investigates the significance of interprofessional collaboration in healthcare settings. The authors underline the need for healthcare professionals from various professions to work well together to maximize patient care results. Foster, G., Taylor, S. J., Eldridge, S., Ramsay, J., & Griffiths, C. J. (2007). Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd005108.pub2 The authors performed a systematic evaluation to assess the impact of these initiatives on patient outcomes. Self-management education programs led by lay leaders, they discovered, can dramatically increase participants' self-efficacy, health behaviors, and overall quality of life. The paper emphasizes the value of peer-led initiatives for supporting, educating, and empowering people with chronic illnesses. Wennberg, A. M., Anderson, L. R., Cagnin, A., Chen-Edinboro, L. P., & Pini, L. (2023). How both positive and burdensome caregiver experiences are associated with care recipient cognitive performance: Evidence from the National Health and Aging Trends Study and National Study of Caregiving. Frontiers in Public Health, 11, 1130099. https://doi.org/10.3389/fpubh.2023.1130099

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16 The essay emphasizes the significance of considering the caregiver's support and well- being when assessing the outcomes of the care recipient by highlighting the intricate relationship between caregiver experiences and the cognitive functioning of the care recipient. The authors concluded that care recipients' cognitive health may benefit from interventions focusing on caregiver support and easing caregiving strain. Pinelli, V., Stuckey, H. L., & Gonzalo, J. D. (2017). Exploring challenges in the patient’s discharge process from the internal medicine service: A qualitative study of patients’ and providers’ perceptions. Journal of Interprofessional Care, 31(5), 566–574. https://doi.org/10.1080/13561820.2017.1322562 The Journal of Interprofessional Care article "A Qualitative Study of Patients' and Providers' Perceptions" explores the difficulties encountered during the internal medicine service's discharge process from the viewpoints of both patients and medical professionals. The authors examine how patients and healthcare professionals view the discharge process using qualitative research techniques and pinpoint the main issues. Flores, M., Glusman, G., Brogaard, K., Price, N. D., & Hood, L. (2013). P4 medicine: how systems medicine will transform the healthcare sector and society. Personalized Medicine, 10(6), 565–576. https://doi.org/10.2217/pme.13.57 The authors contend that the conventional "one-size-fits-all" approach to medicine is insufficient and suggest a new paradigm based on four fundamental principles: predictive, preventative, personalized, and participatory (P4). They highlight technological advances like as genomics, proteomics, and bioinformatics, which allow for a better knowledge of human biology and disease mechanisms.

17 Jee, S. H., & Cabana, M. D. (2006). Indices for Continuity of Care: A Systematic Review of the Literature. Medical Care Research and Review, 63(2), 158–188. https://doi.org/10.1177/1077558705285294 The article offers a useful tool for researchers and decision-makers to comprehend and choose acceptable indices to assess continuity of care, a critical component of healthcare quality and patient satisfaction. Marcolino, M. S., Oliveira, J. A. Q., D’Agostino, M., Ribeiro, A. L., Alkmim, M. B. M., & Novillo-Ortiz, D. (2018). The Impact of mHealth Interventions: Systematic Review of Systematic Reviews. JMIR MHealth and UHealth, 6(1), e23. https://doi.org/10.2196/mhealth.8873 The authors assess and combine the data of different systematic reviews to provide an overview of the efficacy and effects of mHealth interventions in diverse healthcare settings. The study looks at the effects of mHealth interventions on patient satisfaction, healthcare use, health outcomes, and cost-effectiveness. Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., & Ustun, B. (2007). Depression, chronic diseases, and decrements in health: results from the World Health Surveys. The Lancet, 370(9590), 851–858. https://doi.org/10.1016/s0140- 6736(07)61415-9 Using information from the World Health Surveys, Results from the World Health Surveys" explores the relationship between depressive disorders, chronic illnesses, and deteriorating general health. The study examines the effects of depression on people who have chronic illnesses and how this affects those people's general health. According

18 to the research, people who have depression and chronic diseases both simultaneously suffer from considerable health declines. Norris, S. L., Engelgau, M. M., & Venkat Narayan, K. M. (2001). Effectiveness of Self- Management Training in Type 2 Diabetes: A systematic review of randomized controlled trials. Diabetes Care, 24(3), 561–587. https://doi.org/10.2337/diacare.24.3.561 The article "A Systematic Review of Randomized Controlled Trials" in Diabetes Care includes a systematic review that assesses the performance of self-management education programs in type 2 diabetes. The authors look at different randomized controlled trials (RCTs) to see how self-management treatments affect diabetes outcomes. The review covers a variety of self-management techniques, such as instruction, dietary changes, exercise, and medication adherence. Martínez, Y. V., Prado-Aguilar, C. A., Rascón-Pacheco, R. A., & Valdivia-Martínez, J. J. (2008). Quality of life associated with treatment adherence in patients with type 2 diabetes: a cross-sectional study. BMC Health Services Research, 8(1). https://doi.org/10.1186/1472-6963-8-164 The study used a cross-sectional design to examine the relationship between treatment adherence and a variety of quality-of-life factors, such as physical, psychological, social, and environmental components. The results show a beneficial relationship between treatment adherence and overall quality of life, indicating that patients who follow their treatment plans have greater general well-being. The article emphasizes how crucial it is to encourage treatment compliance in type 2 diabetes care to improve patient outcomes and quality of life.

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19 Kaufman, N. (2012). Using Health Information Technology to Prevent and Treat Diabetes. International Journal of Clinical Practice, 66, 40–48. https://doi.org/10.1111/j.1742-1241.2011.02853.x The author discusses HIT's possible advantages and uses in treating diabetes, including telemedicine, decision support systems, mobile health applications, electronic health records, and telemedicine. The study demonstrates how HIT can enhance diabetes management through improved communication between patients and healthcare professionals, remote monitoring and self-management support, and clinical decision support. Smith, S. M., Paul, G., Kelly, A., Whitford, D. L., O’Shea, E., & O’Dowd, T. (2011). Peer support for patients with type 2 diabetes: cluster randomized controlled trial. BMJ, 342(feb15 1), d715–d715. https://doi.org/10.1136/bmj.d715 In this study, individuals were randomly assigned to either the intervention group, which got peer support, or the control group, which received standard medical care. The results show that patients who got peer support had better diabetic self-management, including better glucose control, more exercise, and better medication adherence. The study also shows that peer support increased psychological well-being, with individuals reporting less diabetes-related distress and enhanced quality of life. Karam, M., Brault, I., Van Durme, T., & Macq, J. (2018). Comparing interprofessional and inter-organizational collaboration in healthcare: A systematic review of the qualitative research. International Journal of Nursing Studies, 79(79), 70–83. https://doi.org/10.1016/j.ijnurstu.2017.11.002

20 The International Journal of Nursing Studies article "A Systematic Review of the Qualitative Research" examines the distinctions between interprofessional and inter- organizational collaboration in healthcare settings. The authors systematically evaluate qualitative research papers to investigate the traits, processes, and consequences related to these two types of collaboration.

Dpaneru Mpdule 8 assignment (1)

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