4.- Industria cárnica y comercio mayorista

Introduction

Over the past few decades, chronic conditions (such as heart disease, hypertension, diabetes, asthma, and depression) have been rapidly replacing acute and infectious diseases as the major cause of death, disease, and disability in the United States.182 _{However, because the prevailing health care} system is based on the diagnosis and treatment of acute illness, it is not well suited for the effective care of chronic illness.

Development of the Chronic Care Model

Clinicians and researchers have devoted significant resources to addressing this problem through chronic disease management, which has evolved into a comprehensive strategy for improving care for people with chronic illness. While disease management programs vary in design and

implementation, almost all promote one or more of the six core elements of the Chronic Care Model (CCM) developed by Ed Wagner and colleagues as a framework for guiding specific quality improvement strategies.183

 Health care organization and leadership: An organizational environment that

systematically supports and encourages chronic illness care through leadership and incentives results in more successful quality improvement activities.184

 Linkage to community resources: Community linkages can provide cost-effective access to

services not available inside the organization, such as nutrition counseling, peer-support groups, and data for patient registries.185

 Support of patient self-management: Individual and group interventions that emphasize

patient empowerment and self-management skills have been shown to be effective in the management of diabetes186 _{as well as asthma and other chronic conditions.}

182 _{Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q 2001;79(4):}

579-612.

183 _{Wagner E. System changes and interventions: delivery system design. Improving Chronic Illness Care. IHI National Forum, Orlando, FL; 2001.} 184 _{Wagner E. System changes and interventions: delivery system design. Improving Chronic Illness Care. IHI National Forum, Orlando, FL; 2001.} 185 _{Wagner E. System changes and interventions: delivery system design. Improving Chronic Illness Care. IHI National Forum, Orlando, FL; 2001.}

 Coordinated delivery system design: Innovations in delivery system design to coordinate

actions of multiple caregivers of diabetics, for example, have led to significant improvements in glycemic control, patient satisfaction, and health care utilization.187

 Clinical decision support: Incorporating evidence-based practice guidelines into registries,

flow sheets, and patient assessment tools can be an effective method for changing provider behavior.188

 Clinical information systems: For example, with access to adequate database software,

health care teams can use disease registries to contact patients to deliver proactive care, implement reminder systems, and generate treatment plans and messages to facilitate patient self-care.189, 190

The model is built on the premise that these six elements work together to create productive

interactions between an informed, activated patient and a prepared, proactive practice team – which is what leads to improvements in outcomes.

What We Know About the Chronic Care Model

According to a recent literature review and survey of reputable programs, there is substantial evidence that chronic disease management strategies “achieve better disease control, higher patient satisfaction, and better adherence to guidelines by redesigning delivery systems to meet the needs of chronically ill patients.”191 _{For example:}

 Acute Depression: A simple but systematic program of feedback to doctors on treatment

recommendations, supplemented with follow up and care management by telephone, was shown to significantly improve primary care treatment of patients with acute depression.192

 Diabetes: In a randomized trial to assess the impact of primary care group visits on the

process and outcome of care for diabetic patients, the intervention group receiving self-

187 _{Sadur CN, Moline N, Costa M, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits.}

Diabetes Care 1999;22(12): 2011-7.

188 _{Wagner E. System changes and interventions: delivery system design. Improving Chronic Illness Care. IHI National Forum, Orlando, FL; 2001.} 189 _{Wagner E. System changes and interventions: delivery system design. Improving Chronic Illness Care. IHI National Forum, Orlando, FL; 2001.} 190 _{Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q 2001;79(4):}

579-612.

191 _{Wagner E. System changes and interventions: delivery system design. Improving Chronic Illness Care. IHI National Forum, Orlando, FL; 2001.} 192 _{Simon GE, VonKorff M, Rutter C, et al. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of}

management support through “mini-clinics” involving teams of providers exhibited better outcomes (including higher patient satisfaction and HbA1c levels) than the control group.193

Interventions Based on Model

Several of the specific interventions described in this guide are drawn from the Chronic Care Model. In particular, two interventions are key elements of this model. Both these interventions are included under “Browse Interventions” section:

 Planned Visits

 Group Visits

For that reason, it is difficult to assess them as stand-alone strategies. Also, while you can implement each of these strategies on their own, it is important to see them as components of a comprehensive and coordinated approach to care. Research studies suggest that the more aspects of the Chronic Care Model you use, the likelier you are to achieve better process and patient outcomes.194

193 _{Wagner EH, Grothaus LC, Sandhu N, et al. Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Diabetes Care}

Appendix 11