1. Introduction to Chronic Disease Management
Foundations For
Community Health Workers
(2nd Edition)
(2016)
Berthold, T., Editor
San Francisco, C.A.: Jossey-Bass
Chapter Sixteen
Copyright ©  by John Wiley & Sons, Inc., or related companies. All rights reserved.
Introduction to Chronic Disease Management

2. Reflection of Last Session
What did you learn?
What reentry did you find out about local reentry programs and resources?
How does incarceration impact community health?
How can CHWs support reentry?
Have students review what they learned from the last session on these key topics.

3. What You Will Learn
Identify some of the most common chronic diseases in the U.S., and discuss health inequalities in rates of chronic disease among populations
Apply the ecological model to analyze the causes and consequences of chronic conditions
Analyze and discuss the limitations of traditional medical models for the treatment of chronic conditions, and ways to integrate medical and public health approaches
Take time to discuss the objectives for today.

4. What You Will Learn
Discuss team-based approaches to the delivery of primary health care, and the role and scope of practice of CHWs within these teams
Analyze and explain the concept of patient empowerment and the self-management of chronic conditions
Discuss the application of client-centered concepts and skills to supporting patients in learning how to effectively manage their own chronic conditions
Take time to discuss the objectives for today.

5. Words to Know Adherence Chronic Condition Concordance Discordance
Medication Management
Panel Management

6. Defining Chronic Conditions
Chronic condition – an illness or health condition that lasts for at least 3 months (typically longer), and are generally slow to progress
Approximately half of adults in the U.S. have at least one chronic condition
Become more common with age; majority of Americans over 65 have one or more
The leading cause of illness, hospitalization, and death in the U.S.
Characterized by highly unequal rates of illness and death among populations, based on factors including income, ethnicity, age, and sex

7. Common Chronic Conditions
Cardiovascular diseases
Hypertension, Coronary heart disease
Diabetes
Respiratory diseases
Asthma, COPD
Mental health conditions
Depression, PTSD, Schizophrenia
Substance abuse
Cancers
Arthritis
Chronic kidney disease
Communicable conditions
HIV, Hepatitis C, and Tuberculosis
Progressive conditions
Alzheimer’s disease
Multiple sclerosis
Muscular dystrophy

8. Leading Factors Access to critical health resources
Agricultural & nutritional policies
Institutional discrimination
Environmental conditions
Political, social, & economic policies
Poverty levels
Society
Access to health care & resources
Access to healthy food
Level of violence
Discrimination
Education & training opportunities
Community services
Environment Access to childcare
Recreation opportunities
Affordable housing
Community
Ecological Model
Promote health & well being
Influence behaviors, including diet & activity
Exposure to stress
Friends/Family
Genetics
Knowledge
Physical activity
Environment
Attitude
Diet & nutrition
Age
Behavior
Tobacco & alcohol
Individual

9. Consequences Increased levels of illness and disability
Less funds available for other community services & public benefits
Loss of social and economic human potential
Increased treatment costs
Community/Society
Financial strain due to treatment costs
Increased caretaking & household responsibilities
Loss of employment, insurance, housing
Increased stress
Emotional strains
Friends/Family
Ecological Model
Condition-specific symptoms; often with increasing severity
Disability & challenges with daily living
Increased levels of stress, anxiety, & depression
Stigma and discrimination
Loss of employment
Fatigue & pain
Individual

10. Treating Chronic Conditions
Behavior Changes
Medications
Physical or Occupational Therapy
Medical Interventions
Mental Health Therapies
Medical Equipment
Assistance
Holistic & Integrative Therapies

11. Health Care Models for Chronic Condition Management
Traditional Medical Model
Concerned with most immediate cause of illness
Role of physician is to share their knowledge and give informed advice; role of patient is to follow the physician’s directions
Emphasizes medical treatments, including medications and individual behavior change
Focus is on individual level of ecological model; often fails to consider social determinants that influence health
Integrating Medical & Public Health Models
Looks beyond current symptoms and risk behaviors to consider how the broader social environment affects their health
Seeks to intervene further “upstream” to prevent the development or progression of illness
Requires providers to study and learn about public health and social conditions the are affecting the lives of their patients

12. Health Care Models for Chronic Condition Management
Team-Based Approaches
Will always include a patient and a licensed provider
May also include key family members, other licensed medical and mental health care providers, panel managers, and front-line providers, such as CHWs
Panel Management
System of coordinating health car for a large group or panel of patients
Goal is to efficiently identify patients with the greatest health risks to provide timely care and prevent the progression of health conditions
Key health information about panel is analyzed and coordinated by a designated staff member, sometimes called a panel manager

13. Health Care Models for Chronic Condition Management
Patient Self-Management
Client-centered approach that supports patients to manage chronic conditions over time, and make decisions about the types of treatments and services they do and don’t want
Commonly includes the following strategies:
Developing health goals and a realistic action plan
Talking with friends, family, and caretakers (asking for help when needed)
Evaluating treatment options, including medication
Managing symptoms
Changing patterns of behavior
Monitoring action plan progress
Making decisions about when to access health care services

14. Self-Management: Finding Reasons to Live - Interview

15. Chronic Conditions & CHW Scope of Practice
In general, tasks and services may include:
Outreach
Health system navigation
Home visits
Providing appropriate referrals
Assistance with panel management
Accompaniment to appointments
Health education
Medication reconciliation and adherence counseling
Client-centered counseling
Action planning for self- management
Health status checks
Case management services
Facilitating support groups
Always ask employer to clarify your role and scope of practice within your clinical team

16. Supporting Patient Self-Management
Involves:
Applying Client-Centered Concepts and Skills
Action Planning
Medication Management
Responding to Ambivalence, Resistance, and Relapse
Providing Follow-up Services
Ending Services (Discharge or Termination)

17. Applying Client-Centered Concepts and Skills
Cultural Humility
Ecological Model
Big Eyes, Big Ears, Small Mouth
Harm Reduction
Motivational Interviewing Utilizing OARS
Honoring Client’s Right to Self-Determination

18. Action Planning: Faculty Interview

19. Action Planning, Diabetes and Exercise: Role Play, Demo

20. Medication Management- Reconciliation
Medication Reconciliation compares the list of prescribed medications with the list of medications the patient is actually taking. For each medication ask the following:
What do you take this medication for?
How often are you supposed to take this medication?
Are you taking the medication (and taking it according to the guidelines)? If the patient isn’t taking the medication, ask them why not.

21. Medication Management - Concordance
Medication Concordance means checking with the patient to see if their understanding about how to take the medication is the same as directed by the prescribing physician or provider.
Concordance means the patient and prescriber have the same understanding
Discordance means the patient and prescriber have different understandings
Approximately 50% of patients don’t understand how to take their medications

22. Medication Management - Adherence
Medication Adherence means the patient is actually taking all of the medications correctly, as prescribed. Nonadherence means they patient is not taking medications as prescribed.
Nonadherence may mean the patient stopped taking the medication, is taking a different dosage, or only takes the medications sometimes
Important to understand why the patient is nonadherent
What are some of the reasons a patient may be nonadherent?

23. How to Read a Medication Label

24. Medication Management, Part 1: Role Play, Demo

25. Medication Management, Part 2: Role Play, Demo

26. Medication Management, Part 3: Role Play, Demo

27. Medication Management, Part 4: Role Play, Demo

28. Medication Management: Role Play, Demo
What challenges was this patient facing in terms of taking his medications?
What did the CHW do well to support the patient with medications management?
What else might you do to support this patient with medications management?

29. Action Planning, Revising an Action Plan: Role Play, Counter

30. Action Planning, Revising an Action Plan: Role Play, Demo

31. Action Planning, Revising an Action Plan
What got in the way of Keisha Mitchell’s action plan? What factors made it difficult for her to be successful?
What did the CHW do well, and not so well, in these roll plays? How may the CHW’s approach have affected Keisha Mitchell?
What else would you want to do or say if you were the CHW working to support Keisha Mitchell in this role play scenario?

32. Action Planning, Revising an Action Plan: Faculty Interview

33. Follow-Up Services
Supporting clients to learn and apply new knowledge and skills, and to gain confidence in their ability to manage their chronic conditions
Strengthening professional relationship with clients
Addressing client’s current priorities and concerns
Assessing current health indicators
Reviewing and discussing information about specific health conditions
Reviewing existing action plan steps and goals
Reviewing guidelines for taking medication correctly
Checking in about previous referrals

34. Ending Services Thank them for the opportunity to work together
Review the client’s plan for self-management
Review what the client will do if their health worsens, and what symptoms to watch for
Discuss relapse prevention and what to do in the case of a relapse
Ask the client to summarize their key accomplishments, including what they have learned
Affirm the knowledge, skills, and confidence the client has gained
Ask if they would like to provide feedback regarding their service

35. Patient Initiated Termination
If a patient terminates services because they are unsatisfied with the quality of care, try to end the relationship as peacefully and respectfully as possible.
Listen without judgement or defensiveness
Honor and accept the patient’s decision
Stop and reflect on the feedback provided. What could you have done differently?
If you can do so authentically, apologize for any mistakes or missed opportunities you or your colleagues have made
Wish the client well
If appropriate, keep the door open for their return to service
Review current treatment protocols, including medications

36. Staying Informed National Institutions
Reputable Sources of Online Information
National Institutions
The U.S. Centers for Disease Control and Prevention
National Institutes of Health
The National Institute of Mental health
The National Cancer Institute
The Library of Medicine
Non-Profit Professional Organizations
The American Heart Association
The American Cancer Society
Foundation for Women’s Cancer
Leading Educational & Health Care Institutions
The Mayo Clinic
The Harvard Medical School
The Harvard School of Public Health
The World Health Organization

37. Practice
 Research data on chronic disease in your area and discover the most prevalent conditions affecting your community
Complete Chapter 16 HW & DB in Blackboard
Read Chapter 17

38. Resources: Image on slide 2
digital-drugs-binaural-beats by digitalbob8 is licensed under CC BY 2.0
Image on slide 3
Bring Light Bulb is available in the public domain under CC0 Public Domain
Video on slide 13
Self Management: Finding Reasons to Live: Interview, Foundations by Foundations for Community Health Workers is licensed under a Standard YouTube License
Video on slide 17
Action Planning, Revising an Action Plan: Faculty Interview, Training Guide by Foundations for Community Health Workers is licensed under a Standard YouTube License
Video on slide 18
Action Planning, Diabetes and Exercise: Role Play, Demo, Foundations by Foundations for Community Health Workers is licensed under a Standard YouTube License
Video on slide 23
Medications Management, Part 1: Role Play, Demo, Foundations by Foundations for Community Health Workers is licensed under a Standard YouTube License
Video on slide 24
Medications Management, Part 2: Role Play, Demo, Foundations by Foundations for Community Health Workers is licensed under a Standard YouTube License

39. Resources: Video on slide 25
Medications Management, Part 3: Role Play, Demo, Foundations by Foundations for Community Health Workers is licensed under a Standard YouTube License
Video on slide 26
Medications Management, Part 4: Role Play, Demo, Foundations by Foundations for Community Health Workers is licensed under a Standard YouTube License
Video on slide 28
Action Planning, Revising an Action Plan: Role Play, Counter by Foundations for Community Health Workers is licensed under a Standard YouTube License
Video on slide 29
Action Planning, Revising an Action Plan: Role Play, Demo by Foundations for Community Health Workers is licensed under a Standard YouTube License
Video on slide 31
Action Planning, Revising an Action Plan: Faculty Interview, Training Guide by Foundations for Community Health Workers is licensed under a Standard YouTube License
Image on slide 36
Virginia Mason Hospital Door-2 by Visitor7 is licensed under CC BY-SA 3.0

40. Acknowledgements: MoSTEMWINs
Adapted from the Foundations for Community Health Workers, 2nd Edition (Berthold) with permission from Wiley Publishing.
Unless otherwise noted this material by St. Louis Community College is licensed under a Creative Commons Attribution 4.0 International License.
This product is partially funded by the MoSTEMWINs $19.7 million grant from the U.S. Department of Labor Employment and Training Administration. The product was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership
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