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Improving Health for Individuals with Multiple Chronic Conditions: Recent Actions by HHS Agencies

The strategic framework for multiple chronic conditions seeks to improve the health status of individuals with multiple chronic conditions by guiding HHS in coordinating its efforts internally and collaborating with stakeholders externally. It is designed to address the spectrum of all population groups with multiple chronic conditions (MCC) through four overarching goals:

  1. Fostering health care and public health system changes to improve the health of individuals with multiple chronic conditions.
  2. Maximizing the use of proven self-care management and other services by individuals with multiple chronic conditions.
  3. Providing better tools and information to health care, public health, and social services workers who deliver care to individuals with multiple chronic conditions.
  4. Facilitating research to fill knowledge gaps about, and interventions and systems to benefit, individuals with multiple chronic conditions.

2011 Implementation Actions by HHS Agencies

Administration on Aging/Centers for Medicare and Medicaid Services (AoA/CMS) – Framework Goals 1 and 2

Most older Americans have multiple chronic conditions (MCC). AoA and CMS have jointly announced $67 million in grants that encourage outreach activities to support programs on prevention and wellness, options counseling and assistance, and care transition. This effort is aligned with specific objectives in the MCC framework that encourage the facilitation of home and community-based services, as well as the implementation of care coordination models that lead to improved health outcomes.

Agency for Healthcare Research and Quality (AHRQ) – Framework Goal 4

AHRQ awarded more than $18 million dollars in American Recovery and Reinvestment Act funds for two categories of grant awards to optimize care for people with MCC. One grant focused on research infrastructure development. The second grant compared different strategies in the prevention and management of chronic illness in persons with specific constellations of co-occurring conditions. This effort is aligned with specific objectives in the MCC framework to facilitate research to discover the most effective ways to manage care for individuals with MCC.

Assistant Secretary for Planning and Evaluation (ASPE) – Framework Goal 3

As part of an existing $40 million ASPE contract, the National Quality Forum (NQF) developed and endorsed a performance measurement framework for individuals with MCC. This framework will establish the definitions, domains and guiding principles that are instrumental for measuring and reporting the quality and cost of care for individuals with MCC. This effort is aligned with specific objectives in the MCC framework to develop, endorse, and use key quality metrics to promote best practices in the care of individuals with MCC.

Centers for Disease Control and Prevention (CDC) – Framework Goals 1 and 4

CDC is supporting a new project, titled Living Well with Chronic Disease: Public Health Action to Reduce Disability and Improve Functioning and Quality of Life[PDF], in which the Institute of Medicine (IOM) convened a committee of independent experts to examine the ongoing burden of MCC and the implications for population-based public health action. CDC also funded a project examining the impact of cognitive impairment on co-occurring chronic conditions. This project, awarded to the University of Washington and conducted in collaboration with CDC’s Healthy Aging Research Network, gathered information that assists public health practitioners at local, state and national levels in understanding the effects of cognitive impairment on chronic conditions, and how design and delivery of evidence-based programs for disease management are affected by increasing rates of cognitive impairment. These efforts are aligned with specific objectives in the MCC framework to better understand the epidemiology of MCC and to identify public health policies to improve the care of individuals with MCC.

Centers for Medicare and Medicaid Services (CMS) – Framework Goals 1 and 2

Through the Medicaid program, CMS supported its state partners in providing technical assistance for quality home and community-based services, innovative service delivery models, and person-centered programs and practices. CMS has provided guidance to state Medicaid directors [PDF] on an optional benefit that has been available since January 1, 2011, through the Affordable Care Act.  This state benefit will provide health homes to enrollees who have at least two chronic conditions, as well as to those who have one chronic condition, but are deemed to be at risk for another. Services include comprehensive case management, care coordination, health promotion, transitional care, individual and family support, referral to necessary services, and the use of health information technology. This effort is aligned with specific objectives in the MCC framework that encourage facilitating home and community-based services as well as implementing care coordination models that lead to improved health outcomes.

Through the Federal Coordinated Health Care Office and the Center for Medicare and Medicaid Innovation, created under the Affordable Care Act, CMS provided its state partners technical assistance and demonstration opportunities to develop new delivery system and payment models for dual eligibles (individuals eligible for both Medicare and Medicaid coverage). Forty percent of dual eligibles have between two and five chronic conditions, underscoring the need and significant opportunity to develop person-centered models that align the full range of acute, behavioral health, and long-term services that substantially improve quality, coordination, and cost-effectiveness. This effort is aligned with specific objectives in the MCC framework that implement care coordination models that lead to improved health outcomes.

Food and Drug Administration/ Assistant Secretary for Planning and Evaluation (FDA/ASPE) – Framework Goal 4

FDA and ASPE completed a study to examine the extent to which individuals with MCCs are being included or excluded from clinical trials for new therapeutic products. This effort is aligned with specific objectives in the MCC framework to ensure that individuals with MCCs are not unnecessarily excluded from clinical trials, particularly those trials that are used as the regulatory basis for ensuring that drugs are safe and effective in their intended populations and for their intended uses.

Indian Health Service (IHS) – Framework Goals 1, 2 and 3

IHS expanded its Improving Patient Care (IPC) Program to nearly 100 sites across the IHS tribal and urban Indian health system. The IPC Program works to implement the patient-centered medical home model by training care teams, redesigning the health system, promoting self-care management, integrating behavioral health care into primary care, improving the use of health information technology, and employing other innovations. This effort is aligned with specific objectives in the MCC framework that encourage implementing care coordination models, facilitating self-care management, and providing better tools and information to care teams, patients, and caregivers for improved health outcomes for persons with MCC.

National Institutes of Health (NIH) – Framework Goal 4

NIH added an older adult population to its original Systolic Blood Pressure Intervention Trial (SPRINT) to determine whether efforts to attain a lower blood pressure range in this population will reduce cardiovascular and kidney diseases, age-related cognitive decline, and dementia. This study, SPRINT Senior, addressed four of the 10 most common causes of death and disability among adults over age 75 years.

Substance Abuse and Mental Health Services Administration (SAMHSA) – Framework Goal 1

SAMHSA awarded $34 million in new funding to support three main components in the Primary and Behavioral Health Care Integration (PBHCI) Program: services grants, a cross-site evaluation, and a training and technical assistance center. The services grants seek to build the partnerships and infrastructure necessary for grantees to develop or expand their offering of primary health care services to improve health status in persons with behavioral health problems. The Center for Integrated Health Solutions, funded by SAMHSA and the Health Resources and Services Administration, served as a national training and technical assistance center on the bidirectional integration of primary and behavioral health care and related workforce development, and provided technical assistance to PBHCI grantees and entities to address the health care needs of individuals with mental illnesses, and substance use and co-occurring disorders, including individuals seen in Health Centers funded under the Public Health Service Act. The evaluation examined key aspects of the integration of primary and behavioral health care, including which models and/or respective features of integrated care may lead to better mental and physical health outcomes. This effort is aligned with specific objectives in the MCC framework to identify evidence-supported models, including behavioral health integration models, to improve care coordination for persons with MCC.