WHO CARES: Chronic Illness in America
WHO CARES: Chronic Illness in America

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Alan Lazaroff, M.D.Towards a New Vision of Health Care

Can America's health care system reorient itself to meet the needs of chronic care?

While offering the most advanced medical procedures in the world, the U.S. health care system falls short when it comes to chronic care. That's because many chronic conditions are not covered by insurance or government programs. And while U.S. hospitals are the world's most modern, many health care needs are increasingly closer to the home.

"Most people in hospitals don't really have acute conditions," notes Dr. Alan Lazaroff, director of geriatric medicine at the Denver-based Centura Health System. "They have acute exacerbations or complications of their underlying chronic illness." Seventy-five percent of medical costs, notes Richard Bringewatt, president of the National Chronic Care Consortium, are attributable to chronic disease and disability.

People with chronic conditions, says Lazaroff, require more than medical attention. "What's needed is to sit down with somebody and explain to them the role of exercise in their life, or the importance of adherence to diet, or of taking certain medication," he says. "We could be focusing on disease or disability prevention, taking a person who already had diabetes and trying to prevent the complications of the diabetes, like kidney failure and blindness."

Such preventative measures "are really family issues," notes Dr. Pedro "Joe" Greer, assistant dean at the University of Miami School of Medicine. What's needed, Greer says, are the resources to support family members helping one another. The problem is most severe for the poor who frequently end up in the emergency room, says Greer.

Medicare, which doesn't cover home health care, is increasingly ineffective for older Americans who are living longer while managing various chronic conditions. The program can also present legal problems for doctors who try and use it for preventative medicine, according to Lazaroff.

"Medicare is a disease treatment program, not a health promotion or disease prevention program, to the point where if you spend too much time in preventive activities and you bill Medicare, you may be guilty of fraud," he says. This has a chilling effect on physicians who frequently don't understand all the nuances of Medicare's "voluminous and complex rules," Lazaroff adds.

New Solutions for Managing Chronic Problems

As these chronic care dilemmas mount, a growing number of organizations have identified promising approaches to treat chronic conditions, and may provide a model for the future of health care. Some offer counseling and educational services for patients and their families to learn more about coping with the many issues surrounding their illnesses. Others offer a measure of relief by integrating several health care services and even exercise and recreational activities under one roof.

One example is the Program of All-inclusive Care for the Elderly (PACE), which provides a variety of services for elderly patients with multiple chronic diseases. Patients visit day centers three or four days a week, spending time with doctors, aides, physical therapists, participating in activities and recreation, and receiving social services.

Other disease management programs take a similar team approach to chronic illnesses. The Centers for Disease Control recently awarded $10 million to fund asthma counselors at 25 sites around the country. One is Howard University's outreach program in Washington, D.C., which provides resources for uninsured and underinsured pediatric or adults asthma patients, including individualized asthma counseling and education from Master's level social workers. And in 15 states, the Alzheimer's Disease Demonstration Grant program is funding new approaches to early identification, treatment, and community-based care for Alzheimer's.

As promising as these approaches are, finding the prescription for America's chronic care crisis will likely require both additional efforts and profound change. "The fact of the matter health care is in crisis," says Richard Bringewatt, and treatment of chronic illness "is the number one problem. We need to fundamentally shift the nature of how we finance care, how we manage care, how we deliver care. We need to free up the system so it can pay for the kind of home care that's needed."

Faith in Action
A national program of the Robert Wood Johnson Foundation, Faith in Action makes grants to volunteers representing many religious faiths who care for chronically ill people in their community.

Family Caregiver Alliance/National Center on Caregiving
This organization provides a public voice for caregivers, illuminating the daily challenges they face, offering them assistance and championing their cause through education, services, research and advocacy.

Foundation for Health and Aging
A foundation that advocates on behalf of older adults and their special needs. This site offers information on preventive care, self-responsibility and independence, and connections to family and community.

Howard University College of Medicine
Focusing on the needs of the African American community, Howard University trains students to become competent, compassionate physicians who deliver care in communities having a shortage of health personnel.

National Chronic Care Consortium
A mission-driven organization of leading-edge health networks dedicated to transforming the delivery of chronic care services.

National Family Caregivers Association (NFCA)
This association provides support to family caregivers and publicizes caregivers' needs.

National Health Council
An organization dedicated to improving the health of all people, particularly those with chronic diseases and/or disabilities.

Dr. Greer

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