Chronic Disease Management

     In the United States, chronic disease is considered one of the biggest health concerns with nearly half of all Americans diagnosed with at least one chronic disease. Both the prevalence and number of diagnosed chronic conditions increases with age with over three quarters of persons over 65 having multiple chronic conditions (US DHHS, 2016). Data from CMS (2012) indicate that beneficiaries with chronic diseases represent the highest utilizers of healthcare services. Further, beneficiaries with multiple chronic conditions account for over 90% of all healthcare costs (CMS, 2012). The most prevalent diagnoses were cardiovascular conditions with nearly 79 million Americans diagnosed with hypertension in 2016, followed by arthritis (Waters & Graf, 2018). Given the prevalence of chronic conditions, managing these diseases is imperative in order to improve overall health outcomes and manage costs (US DHHS, 2010). Given how complex medical management can be for PACE participants with multiple chronic conditions, the addition of the occupational therapist can help identify and address barriers to successful management.

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Role of Occupational Therapy. According to the AOTA Practice Framework (2014), medical management falls under the scope of IADLs, however Winship, Ivy, & Etz (2019) consider chronic disease medical management as its own occupation given its complexity. Occupational therapists are trained in physical and psychiatric disease and disability, including assessing the complex needs of those with chronic diseases. Participants may have challenges with management due to personal factors (e.g. cognitive deficits limit understanding of medication regimen; physical deficits limit the ability to engage in necessary health management tasks such as opening pill bottles, exercising, etc). The environment many not support the ability to manage chronic diseases (e.g. participants live a long distance from the PACE center and find it difficult to access care in the clinic; family members often eat fast food and do not encourage a diabetic diet, etc.). Or the disease management task may need to be modified to support adherence (e.g. a person with poor short-term memory forgets to take medications but does much better with a medication alarm and placing medications next to her toothbrush; a person with congestive heart failure who is illiterate and struggles to document daily weights may benefit from a scale with telehealth features that notifies providers of weights, etc.). Occupational therapists are able to determine the barriers to success and find meaningful interventions to support chronic disease management.

 

Disease education. The Chronic Disease Self-Management Program (CDSMP) or a modified version of the CDSMP is a group-based intervention that meets over several weeks with a focus on education, problem solving, and action planning to effectively manage a variety of chronic diseases. This includes tasks from medication management to diet and exercise to coping skills. Groups can be led by an individual with the chronic disease or by a clinician and results have been positive in terms of increasing occupational participation (Smallfield et al., 2019). A modified CDSMP has been shown to be successfully integrated into routine clinic visits, resulting in increased healthy behaviors, decreased depression, and improvements in quality of life (Hevey et al., 2018).

     Other individual and group interventions have been effective at addressing disease specific issues, such as an arthritis group or heart failure group. Focusing on occupational participation in those with chronic disease has also been beneficial (Smallfield et al., 2019). There is insufficient evidence to recommend a specific frequency or duration of treatment as benefits were seen in as few as two sessions and as many three months. The occupational therapist should customize a treatment plan (group versus individual or a combination) and duration for each participant’s needs.

 

Medication Adherence. Medication management and medication adherence is an important aspect of managing chronic diseases, however nearly half of all patients do not take medications as prescribed (Nieuwaalt et al., 2014). The US spends between $100 and $300 billion per year as a result of poor medication adherence (Nieman et al., 2017). Patients with chronic conditions who do not take medications as prescribed are more likely to use the emergency room (ER) and have higher hospitalization rates (Roebuck, Kaestner, & Dougherty, 2018; Simoni-Wistali et al., 2012).

     Schwartz (2017) suggest that medication adherence should be measured through multiple methods such as a pill count and a medication diary. Acceptable adherence rates are generally considered to be 80% (Nieuwaalt et al., 2014), however an acceptable rate for each participant should be clarified with the primary care provider.

     Most patients who miss medication doses, do so unintentionally (Gadkari & McHorney, 2012). There are personal factors that impact medication adherence such as an individual’s health literacy, cognition, psychosocial factors, or beliefs about the medications (Bosworth et al., 2017; Schwartz, 2015). There are also external contributing factors such as drug side effects, cost or burden of obtaining medications, or the quality of the provider-patient relationship (Pages-Puigdemont et al., 2016; Schwartz, 2015). In essence, the factors contributing to medication nonadherence could be due to the person’s abilities and beliefs, the relationship the patient has with the healthcare provider and healthcare system, or be driven by socioeconomic factors, and it likely is a combination of multiple factors. Having a skilled occupational therapist who can thoroughly assess each individual situation and provide a person-centered response is imperative for best outcomes (Bosworth et al., 2017; Schwartz, 2015).

     Motivational interviewing and shared-decision making have been shown to increase patient buy-in and support improvements in medication adherence (Bosworth et al., 2017; Schwartz, 2015). Improving health literacy is another area often targeted by interventions. Providing education in a format that is culturally relevant and understandable to the individual patient has been shown to be effective at improving adherence (Neiman et al., 2018). This again notes the importance of having a patient-centered and individualized approach as educational materials that are useful for one group may not be effective for another.

     Adapting the medication administration process can also be a useful intervention. This may be done through the use of technology and both high-tech and low-tech methods can be effective when individually tailored to the person’s needs. This could include the use of smart phones, simple alarms, or pill sorters (Schwartz & Smith, 2017). It may also include changing the environment or routines to support adherence. For example, it may be suggested that the person who forgets to take their morning dose place their medication vial by the coffee maker as a reminder (Sanders & Van Oss, 2013). Following up with participants to ensure the effectiveness of the intervention and making any further recommendations or adjustments is also key to successful medication adherence (Nieuwaalt, et al., 2014; Schwartz, 2015).