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Improving Health for Individuals with Multiple Chronic Conditions: One-Year Achievements Aligned with the HHS Strategic Framework

The HHS Strategic Framework on Multiple Chronic Conditions seeks to improve the health status of individuals with multiple chronic conditions (MCC) by helping to guide HHS in coordinating its efforts internally and collaborating with stakeholders externally. Issued to the public in December 2010, the strategic framework is designed to address the challenge of MCC across the spectrum of all population groups 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.

In the year since the framework’s release, HHS agencies and external partners have worked to align their respective programs, activities and initiatives with and in support of the framework’s goals, objectives, and strategies.  The inventory of HHS programs, activities, and inventories focused on improving the health of individuals with MCC includes summaries of over 100 HHS such efforts led by the nine HHS agencies.  The following are examples of developments that highlight efforts in direct alignment with the framework’s goals, as well as other selected achievements by HHS and external partners.

One-Year Announcements that Align with the Framework’s Goals

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

Through SAMHSA’s Primary and Behavioral Health Care Integration (PBHCI) grant program, 22,000 adults with mental illness received screening and services for their co-occurring primary care problems. This approach addresses the poor outcomes of individuals with serious mental illnesses and other behavioral health problems that often co-occur with other chronic conditions.

Administration on Aging (AoA) – Framework Goal 2

Through AoA’s Chronic Disease Self-Management Program (CDSMP) initiative, over 50,000 older adults – among whom the majority had MCC – completed an intensive self-care management program. Among these individuals, participation in CDSMP may lead to better symptom control, improved quality of life, deceased emergency room visits, and reduced hospitalizations. 

Assistant Secretary for Planning and Evaluation (ASPE) and the National Quality Forum (NQF) – Framework Goal 3

Despite the growing prevalence of individuals with MCC, few quality measures currently exist for this population. Through ASPE support, the National Quality Forum released a draft performance measurement framework for individuals with MCC for public comment. This framework will establish definitions, domains, and guiding principles to enable measurement and reporting of the quality and cost of care for individuals with MCC.  

Centers for Medicare and Medicaid Services – Framework Goal 4

The new CMS chartbook, Chronic Conditions among Medicare Beneficiaries, provides an important, new source for data on MCC among the fee-for-service Medicare population. Among the many important findings in this chartbook are that two of every 3 Medicare beneficiaries have two or more chronic conditions and that their care accounts for 93% of total Medicare expenditures.  The chart book provides health care professionals and others with original information for better understanding patterns of MCC among the Medicare population and may assist in directing efforts to improve health outcomes and quality of life among individuals with MCC.  

Other selected achievements by HHS agencies and external partners

  • Agency for Healthcare Research & Quality (AHRQ)

AHRQ funded 18 grants on Optimizing Prevention and Healthcare Management for the Complex Patient. Research under these grants improves understanding about which interventions provide the greatest benefit to patients with MCC, how the safety and effectiveness of specific interventions may be affected by comorbid conditions, and how interventions may need to be modified for specific patient populations.  The findings from this research will help clinicians (particularly those in primary care settings) to improve integration of care for patients with MCC, patients to make more informed health care decisions, and policy makers to identify better ways to measure and promote quality care for these complex patients.  A summary of the findings will be available in 2012 at http://www.ahrq.gov/.

AHRQ funded 12 grant projects on Improving Management of Individuals with Complex Health Care Needs through Health IT. These projects address innovative methods, including interactive voice systems and other information systems, and randomized trials to determine how health IT can improve patient self management. The preliminary findings of eight of the projects funded in 2008 will be available in 2012 at http://www.ahrq.gov/.

  • Centers for Medicare and Medicaid Services (CMS)

The Medicaid Health Home State Plan Option, authorized under the Affordable Care Act, allows States to provide a health home benefit which allows for a comprehensive system of care coordination for Medicaid individuals with chronic conditions.  Health home providers integrate and coordinate all primary, acute, behavioral health and long term services and supports to treat the “whole-person.”

This year, CMS approved three health home State plan amendments in two states (Missouri and Rhode Island) and approved 13 health home planning requests from Arizona; West Virginia; Mississippi;  Arkansas; Nevada; New Jersey; New Mexico; North Carolina; California; Washington; Idaho; Alabama; and Wisconsin.  States are required to collect and report information to facilitate a CMS evaluation to understand the impact of the benefit on utilization patterns, expenditures, and quality improvement for Medicaid individuals with MCC.

  • Food and Drug Administration (FDA)

FDA is completing a study that assesses the participation of people with chronic conditions in clinical studies in recent new drug applications. FDA’s study examines whether unnecessary exclusions are limiting the applicability of data in new drug applications.  An issue of particular interest is whether there is a tendency to exclude individuals with histories of psychiatric illness, a potential problem because some drugs appear to exacerbate such illnesses.

  • Health Resources Services Administration (HRSA)

HRSA’s Patient Safety and Clinical Pharmacy Services Collaborative Program involves the efforts of over 160 community-based teams representing 43 states, Washington, D.C., Puerto Rico, and the Virgin Islands. These teams work in interdisciplinary care environments to enhance care coordination around medications to improve health outcomes and patient safety for high-risk patients, many of whom have MCC.  Teams use clinical markers to help guide quality improvement efforts by systematically monitoring their patients.

HRSA also released its Guide for HIV/AIDS Clinical Care, which provides clinicians with ready access to practical, current, treatment information so that they may provide quality care to individuals living with HIV infection. The guide includes chapters on co-morbidities, co-infections, and complications associated with HIV/AIDS.

  • Indian Health Service (IHS)

IHS published its 2011 Standards of Care and Clinical Practice Recommendations for Type 2 Diabetes.  These guidelines are an essential part of the IHS system-wide efforts to continuously improve the quality of care in the Indian Health system.  Updated every two years, these guidelines emphasize areas of unique importance in the care of diabetes, including the care of patients with multiple co-morbid conditions, and support the team approach to diabetes care in Indian health care facilities and surrounding communities.

  • National Institutes of Health (NIH)

Within NIH, the Office of Behavioral and Social Sciences Research issued a funding opportunity announcement (FOA) on Behavioral Interventions to Address Multiple Chronic Health Conditions in Primary Care (R01). This FOA will support research in primary care that uses a multi-disease care management approach to behavioral interventions with the potential for improving health outcomes in individuals with three or more chronic health conditions.

In September 2011, the National Institute on Aging, in collaboration with AHRQ, convened an expert panel on health outcome measures for older persons with MCC.  The expert panel recommended a core set of well-validated outcome measures (based on factors such as validity, reliability, and practicality) whose inclusion in research and in health care databases could enhance evaluation of interventions, population health, and quality of care in older adult patients with MCC. These measures may be helpful in clinical decision-making and assist with quality improvement initiatives. 

  • Substance Abuse and Mental Health Services Administration (SAMHSA)

The SAMHSA / HRSA Center for Integrated Health Solutions provided training and technical resources to 12 states to assist in addressing services for individuals with MCC (per section 2703 of the Affordable Care Act).

  • National Council on Aging (NCOA) – HHS External Partner

A key external partner, NCOA initiated the Self-Care Management Alliance (SMA), a partnership between MCC-relevant organizations to advance goal 2 of the strategic framework and its emphasis on maximizing the use of proven self-care management and other services by individuals with MCC.

Find out more about the new HHS Strategy on Multiple Chronic Conditions.