Integrated care for chronic conditions: The contribution of the ICCC Framework
Introduction
At the beginning of the 1990s, references to a global epidemic of chronic conditions became increasingly common. Analysis of the global burden of disease confirmed this reality and revealed the impact of these pathologies [1]: it is now clear that they represent one of the principal challenges for health systems today.
Experts have estimated [2], [3], [4] that before 2030 chronic diseases will account for 70% of the global disease burden and will be responsible for 80% of deaths across the world. In developing countries, noncommunicable diseases (NCDs) in particular will represent 65% of the disease burden, with 80% of global deaths due to this type of diseases occurring in low- and middle-income countries.
In this context, it is notable that the majority of health systems continue to be mainly organised around an acute, reactive and episodic model of care that no longer meets the needs of patients with chronic conditions and multiple pathologies, or individuals at risk of developing these [5].
The traditional approach to healthcare is based on a concept of illnesses with abrupt onset and limited duration, which can be usually cured by health professionals. Chronic conditions however do not fit with this concept. Among other characteristics, their appearance is usually gradual, their development progressive and their treatment complex. As a consequence, patients with chronic disease have to cope with their condition and its effects, which often have a significant impact on their quality of life, over a long period of time. Such patients therefore have experience and knowledge on their condition complementary to that of health professionals, a factor which current health systems often neglect [6].
In the current healthcare model, the intervention of the system usually responds to a patient-initiated search for care, associated with an acute episode of disease. In this reactive model there is little opportunity for planning and for involving a wide variety of health professionals, resulting in a physician-centred model of care. Specifically, a physician often undertakes a whole set of tasks in the short period of time available in an unplanned consultation: reviewing the patient's medical history, requesting tests and/or checking results thereof, carrying out routine preventive care, reviewing treatments, making referrals to specialists as required, and completing forms, in addition to diagnosing and dealing with an acute attack, and reassuring the patient and his/her family [7]. Most such consultations are, however, due to symptoms and acute exacerbations of chronic diseases, which could be foreseen and planned for to some extent. For example, it has been estimated that about 80% of interactions with the healthcare system and 77% of health expenditure in the Basque Country (Spain) are due to chronic conditions [8]. These data are similar to those obtained in other geographical contexts, such as in England [9].
In relation to this, under the current model of care, patients leave their doctor's office recalling and understanding about 50% of what they have been told [10], only around 56% of care processes provided for chronic conditions involve recommended care [11], and, indeed, only 45% of doctors consider that “people with chronic medical conditions usually receive adequate medical care” [12], according to studies on the quality of primary care in the US. It is therefore unsurprising that, in a survey of primary care physicians in eleven OECD countries published in 2009, it was found that most physicians in nine of these countries considered that the healthcare systems in which they worked needed fundamental changes or to be completely rebuilt [13].
Additionally, fragmented care is commonplace and translates into patients receiving a notoriously low quality care [14]. This is especially alarming in the case of individuals with chronic conditions, who particularly benefit from continued and regular contact with a health system [15].
Given all this, integration of care is one of the ongoing challenges of health systems both from the perspective of patients and professionals, and in terms of the management of resources for the provision of health and social services [16], [17], [18]. Shortcomings in continuity, communication, coordination, and integration, which lead to various problems of under- and overuse, as well as inappropriate use, of services, are obstacles to achieving optimal care processes. In particular, insufficient integration tends to result in overcrowding, delays, errors, and other undesirable effects leading in turn to inefficiency, disappointment, and general dissatisfaction [19].
Section snippets
Chronic care and population management models
In view of the growing epidemic of chronic diseases, the World Health Organisation proposed a model for change in health systems in 2002, the Innovative Care for Chronic Conditions (ICCC) Framework [20]. In this article, we aim to highlight the current relevance of the ICCC framework and to assess both its conceptual and practical contribution to policy development and health system transformation. The ICCC Framework took as its reference the Chronic Care Model (CCM) [14], a pre-existing
The process of seeking a framework
The WHO's Department of Noncommunicable Disease Management initiated the “Innovative Care for Chronic Conditions” project in 2000 [28]. This project was motivated by the results of a previous consultation process [29] which had concluded that, despite the existence of effective and cost-effective interventions for the prevention and control of chronic conditions, these were not used systematically. Consequently, they were not reaching all the patients who could benefit from them, either in
The Innovative Care for Chronic Conditions Framework
Though the ICCC Framework does not dictate specific changes, it serves as a roadmap for policy development and health system redesign. The “building blocks” of the ICCC Framework (shown in Fig. 1) can be used to create or redesign healthcare systems. It also provides a global framework to harmonise initiatives aimed at improving chronic patient care.
Key characteristics of the framework are that it incorporates a health policy perspective and can be used as a reference for the comparative
Main contributions of the ICCC Framework to chronic care
Though based on the CCM, the ICCC aimed to be relevant to a wider international context [34]. The CCM was founded on evidence from high income countries and drew especially on experiences from the US. The ICCC Framework, on the other hand, adapts better to the context of health policy development in low- and middle-income countries, particularly given: (a) the explicit and prominent role given to the broader policy environment, (b) the consideration of the roles of the community and the
Experience with the ICCC Framework
Despite the fact that the WHO discontinued this line of work in 2006, the ICCC Framework has served as a reference for designing, planning and piloting care for chronic patients around the world.
In particular, policy makers have used the framework for policy development, healthcare redesign and analysis in very different countries: Australia, Morocco, Rwanda, the Russian Federation, and Spain. In relation to strategic approaches to chronic care by policy makers, among other places, it has
Evidence on effectiveness of the ICCC Framework
In spite of the aforementioned influence of the ICCC Framework, we have not identified any studies in the literature that explicitly assess its implementation in a comprehensive manner throughout an entire health system.
However, many components of the ICCC Framework have been verified in the literature on the CCM. Indeed, there are several systematic reviews [70], [71] and meta-analyses [72] assessing the impact of the Chronic Care Model, in addition to individual studies. In many cases, health
Limitations of this review
The review of the contribution to date of the ICCC model to improvements in the care of chronic patients conducted in this paper is constrained by several limitations. Firstly, we searched for studies in which explicit reference was made to the use of the ICCC Framework, or alternatively, to the CCM model. There might be other initiatives inspired by the ICCC model, but which make no explicit reference to it, that have not been included.
Secondly, the multi-level, comprehensive nature of the
Conclusions
Chronicity offers an opportunity for rethinking healthcare systems, and for orienting them towards a more integrated response to health needs [92]. As growing numbers of stakeholders are becoming aware of the need to reorient health systems towards better care for chronically ill patients, the ICCC Framework will continue to serve as a road map for transformation.
The ambition of the ICCC was to complement the components of the CCM. Its additions, particularly at the macro level, were intended
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