Applying Business and Other Models to Chronic Disease Prevention

In order to solve complicated problems, it is often helpful to draw on other disciplines that may provide alternative solutions. The chronic disease epidemic is certainly a problem that asks us to consider the use of new and different models, including successful business models used by the private sector of the economy. Remington, Brownson, and Wegner (2010) argue that to achieve success in the battle against chronic diseases, any effort must consider the multiple determinants of the development of these diseases. The determinants of a chronic disease include personal health behaviors, the physical environment, social and economic factors, and the system of health care delivery available to the individual. In consideration of these multiple complex determinants, successful intervention to reverse the growth of the chronic disease epidemic can best be achieved by a collaborative, community-based population strategy.

The Chronic Care Model

Bernstein (2008) points to a model that represents a major change in the care of patients with chronic diseases, dubbed the chronic care model. This new method of treating patients with chronic diseases entails collaboration between an informed patient and a health care team that is proactive in preventing complications from the patient's chronic disease(s). This is an evidence-based system of health care delivery, where disease is handled proactively by health care providers who actively measure and track patient outcomes.

chronic care model

A collaboration between an informed patient and a health care team that is proactive in preventing chronic disease complications.

evidence-based system

A system in which health care decisions are made through the conscientious, explicit, and judicious use of current best evidence from relevant and valid research.

According to Glasgow, Orleans, and Wagner (2001), the chronic care model offers a template for the care of chronic diseases that is evidence- based, population-based, and patient-centered. The health system that applies this model will know the value of best practices from population and clinical studies, be concerned about the health of the patient, and be very aware of what the patient wants and needs to know about his or her health. This is a tall order for a health care system that has trained providers of care to deal with individual patients and not to be very concerned about population health. These same providers of care may also be unaware of the recommended best practices for preventing chronic diseases and their complications.

These components of care found in the chronic care model entail both the prevention of these devastating diseases and the management of chronic diseases if and when they do occur. Glasgow et al. (2001) discuss the important parts of the chronic care model, which include “making chronic illness care a key goal of the organization, ensuring that leadership is committed and visibly involved, instilling support for change and quality- improvement trials, and realigning or creating incentives for providers and patients to improve care and adhere to evidence-based guidelines (including both financial and nonfinancial incentives, such as recognition and status)” (p. 585). The keywords here are leadership and incentives. The other areas of concern put forth in this template for the care of chronic diseases are self-management support and the utilization of community resources. These components are very important in dealing with the current epidemic of chronic diseases and their many potential complications.

According to Glasgow et al. (2001) self-management support involves preparing patients and their family members to face the challenges that will occur in taking control of their wellness despite the occurrence of one or multiple chronic diseases. The patients and their families who take on this responsibility require the availability of tailored educational resources designed to prevent the potential complications that may result from having a chronic disease for a period of time. It seems obvious that if this use of educational resources could only begin earlier in life, the chronic diseases and other comorbidities could be prevented, avoiding the use of expensive medical resources later in life.

self-management support

Helping the individual to take a supporting role in the management of his or her disease.

The other result of using the chronic care model is that one gains a much better understanding of the need to use community resources in the improvement of the health of a given population. This need to work with the community is where the leadership component of this model becomes so necessary. The importance of these environmental community resources cannot be overstated.

Business Models

Remington et al. (2010) point out that 80 percent of heart disease and type 2 diabetes cases could be prevented through individuals increasing their exercising on a daily basis. This fact alone should encourage all schools and workplaces to increase health education and promotion activities since these programs offer a tremendous return on investment. But lack of exercise is only one of the reasons that the chronic disease epidemic is growing so rapidly. There are many other high-risk health behaviors that are all working together to produce chronic diseases and their complications. It is time to look outside our health care and public health systems for components of a model that can work collaboratively to solve this national epidemic.

Zook and Allen (2012) argue that programs of change must focus energy on the most critical routines that need to change and then concentrate on changing those routines. Although this advice comes from business authors it is very applicable to changing high-risk health behaviors. There are many proven business theories and models that might help us to address the chronic disease epidemic. McChesney, Covey, and Huling (2012) point out that in order to be successful in goal achievement, we need to focus our maximum effort on one or two important goals, rather than giving minimum effort to a larger number of goals. In The 4 Disciplines of Execution, these authors outline a step-by-step procedure for the achievement of major goals: focus on the wildly important, act on the lead measures, keep a compelling scoreboard, and create a cadence of accountability. Although this procedure was developed for business applications, it offers great potential for dealing with chronic diseases on both an individual and population basis.

The process of execution begins with success. Gallo (2011) points out that Steve Jobs, one of the most successful innovators of all time, stated that his successful innovations involved nothing more than keeping them simple to understand and simple to use. In order to deal with the change required to reduce the epidemic of chronic diseases, we need to look at a change model that has been successful in business in recent years.

Figure 12.7 provides a diagram of a process of change that could be very useful in improving the health of the population. The outer core of this diagram calls for those involved in bringing about change to be resolute and to complete an evaluation in order to know the impact of the change process. The inner core of the change process, as proposed by Fullan (2011), involves motivating the masses, which surely needs to be a goal of population-based health education programs. Another inner process in this particular model is collaboration, which is also necessary to make community-based health education and promotion programs successful. This diagram of the components of the change process is helpful for the individual attempting to change high-risk health behaviors.

These business models are also applicable to the development of wellness programs and the successful execution of these programs by their participants. Prevention programs tend to fail in the long term because they are often too complicated and try to accomplish too much with limited resources. The entire concept of wellness needs to be simplified. Let's examine another opportunity to successfully apply a business model to a population-based health problem. Fos and Fine (2005) argue that the

The Change Leader

Figure 12.7 The Change Leader

Source: Fullan, 2011, p. 24.

Example of a Flowchart Applied to a Health Problem

Figure 12.8 Example of a Flowchart Applied to a Health Problem

Source: Fos & Fine, 2005, p.191.

practice of creating flowcharts can easily be applied to health problems and managerial decision making.

Figure 12.8 displays a flowchart that is being used to assist individuals in following a weight reduction program. This is another example of a business tool that could be easily adapted to preventive health efforts both on an individual and a population basis. According to Fos and Fine (2005), flowcharts are extremely useful for describing a process along with identifying variation, which can then lead to correction of the variation and the building of a best process. The process of designing this tool can help program managers develop effective chronic disease prevention programs, and the tool itself can guide participants so that they can spot and respond to behavioral or outcome variations and stick with best processes or practices.

Figure 12.9 shows the model for improvement, another model from business that can be applied to the current epidemic of chronic diseases. This model employs a set of questions and the PDSA cycle originally discussed many years ago by W. Edwards Deming. As Healey and Zimmerman (2010) have pointed out, the Deming cycle of PDSA (Plan, Do, Study, Act) is a very appropriate model for use with health education and health

The Model for Improvement

Figure 12.9 The Model for Improvement

Source: Provost & Murray, 2011, p. 4.

promotion efforts. Provost and Murray (2011), too, find that the PDSA cycle is widely applicable and easy to understand and utilize in numerous improvement efforts. Normally used in the improvement of business processes, it can be used to improve the results of many current initiatives for preventing the development of chronic diseases in the population. It can also be used with people who already have one or more chronic diseases. In the example later in this section, we will be designing a program to prevent the possible complications from chronic diseases.

model for improvement

A model from business that focuses on outcomes and can be used to improve chronic disease management.

Deming cycle of PDSA (Plan, Do, Study, Act)

A management method used by businesses for the continuous improvement of quality.

In this model three fundamental questions form the basis for improvement:

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in improvement?

[Provost & Murray, 2011, p. 4].

It is not difficult to apply the PDSA cycle and attempt to answer these questions in the development of population-based chronic disease prevention and care programs. The following example of answering the questions uses the population-based problem of overweight and obesity.

What Are We Trying to Accomplish?

Provost and Murray (2011) argue that in order to improve a situation (such as the incidence of complications from overweight and obesity), all the important stakeholders need to agree on the reason for this effort The best way to accomplish this critical component of the proposed program is to develop and agree upon an aim statement that is clear, concise, and results oriented. Here's a sample aim statement for our proposed overweight and obesity reduction program.


Community Weight Reduction Program

During the next year, the Wellness Task Force will reduce the average weight of the residents of County A by 20 percent.

Guidance: The focus for this weight reduction project will be health education programs for schools in the district on good nutrition and physical activity and a more advanced program for the workplaces in the county concerning appropriate weight and the value of physical activity.

How Will We Know That a Change Is an Improvement?

In order to keep community involvement high, there needs to be feedback that tells program managers whether or not the intervention is actually moving toward goal achievement. For example, measures of change in this project could be

• Percentage of children in the school district who are actively participating in the weight-loss program through improved nutrition and physical activity programs.

• Percentage of workplaces in the county that are actively participating in the weight-loss program through improved nutrition and physical activity programs.

What Change Can We Make That Will Result in Improvement?

According to Provost and Murray (2011), in many instances “the knowledge to support a specific change has existed for some time, but the conditions, resources, or inclination did not exist to make the change happen” (p. 7). This is the exact condition that we have been experiencing with the chronic disease epidemic in the United States.

For instance, Matthews et al. (2008) argue that Americans spend a large majority of their time in behaviors that are sedentary. The human body was not designed to be sedentary but is, rather, an amazing creation that thrives when physical activity becomes part of its daily routine. Lack of physical activity is contributing to our weight gain and subsequent development of chronic diseases. Increasing physical activity is a change that could drive prevention of these diseases or of their complications.

Another missing ingredient in chronic disease management that we have known about for some time is the way Medicare and most other insurers pay for care. Health care payment systems focus on activities performed by various providers rather than outcomes delivered by those providers. This focus on activities can result in enormous increases in health care costs, especially in the last several months of life when chronic diseases do the most damage but major interventions nevertheless often yield very poor outcomes. Having payment systems that focus more on outcomes is a change that might make real differences in the assistance people receive to manage their weight

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