Managing chronic conditions is seen as the public health challenge of the 21st century. The number of Americans with chronic conditions is expected to rise to 157 million by 2020. Diabetes prevalence and costs contribute to the growing problem. Diabetes was the seventh leading cause of death in 2006. Nationally, the cost of diabetes is expected to be $138 billion in 2020. Diabetes leads to multiple and significant complications. The desired outcomes of management of chronic conditions are improvement in clinical status, avoidance of complications, prevention of co-morbid conditions and avoidance of the costs associated with complications. In the 1990s, disease management programs were implemented in an attempt to effectively manage chronic conditions. The primary approach in these programs focuses on individual-level interventions. Despite these efforts, poor outcomes exist. As a result, other approaches to diabetes management are being explored. This study examines a system-level approach to diabetes management versus an individual level one. The system level approach is based on full implementation of the Chronic Care Model, framed in Social Ecology Theory. This retrospective, non-experimental study explores changes in adherence to select diabetes screening guidelines based on the approach to adopted by two health plans. Analyses were conducted on adherence to LDL, A1c, retinopathy and nephropathy screening 2 ½ years after program implementation. In addition, logistic regression analyses were conducted on the predictive impact of approach to chronic care management in relation to changes in adherence. Other variables known to impact health behaviors were factored into the analysis. There were two main findings of the study. The first is that for each of the screenings, there was a statistically significant difference between participants in the two plans. Comparisons of changes in adherence by approach from before implementation to after implementation resulted in a small number of subjects in some cells which can lead to accepting the null hypothesis when it is false. The second is that approach to management was associated with changes in adherence to three of the four screenings. The logistic models, however, account for less than 23% of the variance in adherence, a moderate effect size.

The purpose of this project was to design a chronic care plan using the chronic care management (CCM) framework to improve health services at lower healthcare costs. The practice-focused question explored whether the operationalization of the CCM model would impact progress toward the management of chronic illness for the target population of Medicare beneficiaries with 2 or more chronic illnesses in an urban acute care agency located in the western United States. The middle-range theory, logic rational plan model, Lewin’s change theory, and the CCM’s coordination care and collaborative care concepts were used to guide the project. Data were collected from nursing databases and government agencies. Nurses were significant to the CCM reform by supporting the elements for proactive care. Nurse practitioners can bill using the CCM codes, and clinical nurses can performed patient sensitive care. The social changes were patients with chronic illnesses realized a better quality of life at lower health costs.