Reference this article for chronic conditions and interventions.
The following are brief definitions for the 27 chronic conditions identified by the Centers for Medicare and Medicaid Services in its chronic conditions data warehouse. Links to evidence-based diagnosis and treatment recommendations for each condition are provided for reference.
2. AMI – Acute Myocardial Infarction (i.e., heart attack)
4. Anemia
5. Asthma
7. Benign Prostatic Hyperplasia
8. Cataract
9. Chronic Kidney Disease (CKD)
10. Chronic Obstructive Pulmonary Disease and Bronchiectasis
11. Depression
12. Diabetes
13. Glaucoma
14. Heart Failure
16. Hyperlipidemia
17. Hypertension
19. Osteoporosis
20. RA /OA (Rheumatoid Arthritis / Osteoarthritis)
21. Stroke / Transient Ischemic Attack (TIA)
22. TIA: A transient ischemic attack (TIA)
25. Prostate Cancer
26. Lung Cancer
Risk-based Recommendations for Intervention
1. Acquired Hypothyroidism - Hypothyroidism is a common endocrine disorder resulting from deficiency of thyroid hormone. In the United States and other areas of adequate iodine intake, autoimmune thyroid disease (Hashimoto disease) is the most common cause of hypothyroidism; worldwide, iodine deficiency remains the foremost cause.
UpToDate – www.uptodate.com/contents/search?sp=0&source=USER_PREF&search=hypothyroidism&searchType=PLAIN_TEXT
Medscape – http://emedicine.medscape.com/article/122393-overview
2. AMI – Acute Myocardial Infarction (i.e., heart attack) is the irreversible necrosis of heart muscle secondary to prolonged ischemia. Approximately 1.5 million cases of MI occur annually in the United States.
Medscape – www.emedicine.medscape.com/article/155919-overview
3. Alzheimer's Disease – Alzheimer disease (AD) is an acquired disorder of cognitive and behavioral impairment that markedly interferes with social and occupational functioning. It is an incurable disease with a long and progressive course. In AD, plaques develop in the hippocampus, a structure deep in the brain that helps to encode memories, and in other areas of the cerebral cortex that are used in thinking and making decisions.
Medscape – www.emedicine.medscape.com/article/1134817-overview
Alzheimer's Disease and Related Disorders / Senile Dementia - Alzheimer disease (AD) is an acquired disorder of cognitive and behavioral impairment that markedly interferes with social and occupational functioning. It is an incurable disease with a long and progressive course. In AD, plaques develop in the hippocampus, a structure deep in the brain that helps to encode memories, and in other areas of the cerebral cortex that are used in thinking and making decisions.
Medscape – www.emedicine.medscape.com/article/1134817-overview
4. Anemia – Anemia is strictly defined as a decrease in red blood cell (RBC) mass. The function of the RBC is to deliver oxygen from the lungs to the tissues and carbon dioxide from the tissues to the lungs.
Medscape – www.emedicine.medscape.com/article/198475-overview
5. Asthma – Asthma is a common chronic disease worldwide and affects approximately 24 million persons in the United States. It is the most common chronic disease in childhood, affecting an estimated 7 million children. The pathophysiology of asthma is complex and involves airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness.
Medscape – www.emedicine.medscape.com/article/296301-overview
6. Atrial Fibrillation - Atrial fibrillation (AF) has strong associations with other cardiovascular diseases, such as heart failure, coronary artery disease (CAD), valvular heart disease, diabetes mellitus, and hypertension.
UpToDate -www.uptodate.com/contents/search?search=atrial+fibrillation&sp=0&searchType=PLAIN_TEXT&source=USER_INPUT&searchControl=TOP_PULLDOWN&searchOffset=&autoComplete=true
Medscape – www.emedicine.medscape.com/article/151066-overview
7. Benign Prostatic Hyperplasia – Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. Chronic bladder outlet obstruction (BOO) secondary to BPH may lead to urinary retention, renal insufficiency, recurrent urinary tract infections, gross hematuria, and bladder calculi.
Medscape – www.emedicine.medscape.com/article/437359-overview
8. Cataract - Senile cataract is an age-related, vision-impairing disease characterized by gradual, progressive thickening of the lens of the eye. It is one of the world’s leading causes of blindness.
UpToDate – www.uptodate.com/contents/search?sp=1&source=USER_PREF&search=cataract&searchType=PLAIN_TEXT
Medscape – www.emedicine.medscape.com/article/1210914-overview
9. Chronic Kidney Disease (CKD) - Chronic kidney disease (CKD) is a common condition in which there is a loss of kidney function over time. CKD is associated with an increased risk of cardiovascular disease and chronic renal failure. Kidney disease is the ninth leading cause of death in the United States.
Medscape – www.emedicine.medscape.com/article/238798-overview
10. Chronic Obstructive Pulmonary Disease and Bronchiectasis - Chronic obstructive pulmonary disease (COPD) is estimated to affect 32 million persons in the United States and is the fourth leading cause of death in this country. Patients typically have symptoms of chronic bronchitis and emphysema, but the classic triad also includes asthma.
Medscape – www.emedicine.medscape.com/article/297664-overview
11. Depression - Major depressive disorder has significant potential morbidity and mortality, contributing to suicide, incidence and adverse outcomes of medical illness, disruption in interpersonal relationships, substance abuse, and lost work time.
Medscape – www.emedicine.medscape.com/article/286759-overview
12. Diabetes - Type 2 diabetes mellitus consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion.
Medscape – www.emedicine.medscape.com/article/117853-overview
13. Glaucoma - Chronic angle-closure glaucoma (CACG) refers to an eye in which portions of the anterior chamber angle are closed permanently by peripheral anterior synechiae (PAS). Variable and sometimes conflicting terminology has been used to describe different appearing forms.
Medscape – www.emedicine.medscape.com/article/1205154-overview
14. Heart Failure - Heart failure develops when the heart, via an abnormality of cardiac function (detectable or not), fails to pump blood at a rate commensurate with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressure.
Medscape – www.emedicine.medscape.com/article/163062-overview
15. Hip / Pelvic Fracture - A total of 310,000 individuals were hospitalized with hip fractures in the United States alone in 2003, according to data from the United States AHRQ, accounting for 30 percent of all hospitalized patients.
Medscape – www.emedicine.medscape.com/article/1247913-overview
16. Hyperlipidemia - This condition is caused by a susceptible genotype aggravated by 1 or more factors, including atherogenic diet (excessive intake of saturated fat, trans fat, and, to a lesser extent, cholesterol), obesity, and sedentary lifestyle. The involved genes have yet to be discovered. Polygenic hypercholesterolemia is associated with an increased risk for coronary heart disease (CHD)
Medscape – www.emedicine.medscape.com/article/121424-overview
17. Hypertension - Hypertension affects approximately 75 million adults in the United States and is a major risk factor for stroke, myocardial infarction, vascular disease, and chronic kidney disease.
Medscape – www.emedicine.medscape.com/article/241381-overview
18. Ischemic Heart Disease - Vascular disease as a consequence of atherosclerosis results in a wide range of conditions making up cardiovascular and peripheral vascular diseases. Vascular disease is, without question, the current leading cause of morbidity and premature deaths of modern era medicine.
Medscape – www.emedicine.medscape.com/article/312052-overview
19. Osteoporosis - Osteoporosis is the most common metabolic bone disease in the United States and can result in devastating physical, psychosocial, and economic consequences. It is often overlooked and undertreated, however, in large part because it is so often clinically silent before manifesting in the form of fracture.
Medscape – www.emedicine.medscape.com/article/330598-overview
20. RA /OA (Rheumatoid Arthritis / Osteoarthritis) - RA: Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of unknown cause. An external trigger (e.g., cigarette smoking, infection, or trauma) that triggers an autoimmune reaction, leading to synovial hypertrophy and chronic joint inflammation along with the potential for extra-articular manifestations, is theorized to occur in genetically susceptible individuals.
Medscape: www.emedicine.medscape.com/article/331715-overview
OA: Osteoarthritis is the most common type of joint disease, affecting more than 20 million individuals in the United States alone. It can be thought of as a degenerative disorder arising from the biochemical breakdown of articular (hyaline) cartilage in the synovial joints.
Medscape: www.emedicine.medscape.com/article/330487-overview
21. Stroke / Transient Ischemic Attack (TIA) - Stroke: Ischemic stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke.
Medscape: www.emedicine.medscape.com/article/1159752-overview
22. TIA: A transient ischemic attack (TIA) is an acute episode of temporary neurologic dysfunction that typically lasts less than an hour; results from focal cerebral, spinal cord, or retinal ischemia; and is not associated with acute tissue infarction. In people who have a TIA, the incidence of subsequent stroke is as high as 11% over the next 7 days and 24-29% over the following 5 years.
Medscape: www.emedicine.medscape.com/article/1910519-overview
23. Female/Male Breast Cancer - Worldwide, breast cancer is the most frequently diagnosed life-threatening cancer in women and the leading cause of cancer death among women.
Medscape – www.emedicine.medscape.com/article/1947145-overview
24. Colorectal Cancer - Colon cancer is the most common type of gastrointestinal cancer. It is a multifactorial disease process, with etiology encompassing genetic factors, environmental exposures (including diet), and inflammatory conditions of the digestive tract.
Medscape – www.emedicine.medscape.com/article/277496-overview
25. Prostate Cancer - Prostate cancer is the most common non-cutaneous cancer in men in the United States. An estimated one in six white men and one in five African-American men will be diagnosed with prostate cancer in their lifetime, with the likelihood increasing with age.
Medscape – www.emedicine.medscape.com/article/1967731-overview
26. Lung Cancer - The term lung cancer, or bronchogenic carcinoma, refers to malignancies that originate in the airways or pulmonary parenchyma. Approximately 95 percent of all lung cancers are classified as either small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC). This distinction is essential for staging, treatment, and prognosis. Other cell types comprise about 5 percent of malignancies arising in the lung.
Medscape
Small cell lung cancer – www.emedicine.medscape.com/article/280104-overview
Non-small cell lung cancer – www.emedicine.medscape.com/article/279960-overview
27. Endometrial Cancer - Endometrial cancer (also referred to as corpus uterine cancer or corpus cancer) is the most frequently occurring female genital cancer; this condition was the fourth most common cancer among US women in 2012. In developed countries, adenocarcinoma of the endometrium is the most common gynecologic cancer.
Medscape – www.emedicine.medscape.com/article/254083-overview
Risk-based Recommendations for Intervention:
The following interventions are recommended based on the level of risk associated with each member. Time should be taken during inpatient and outpatient encounters to initiate these recommendations. Patient outreach should also be undertaken post-discharge and on a periodic basis.
The following recommendations are based on the ACG risk category associated with each patient within this application:
Healthy
- Periodically monitor overall health through an annual health assessment.
- Ensure that all scheduled appointments and physicals are kept.
Low
- Perform multidisciplinary discharge planning ahead of patient discharge.
- Provide patient with disease specific education, including home health referral and make follow-up appointment.
- Make a follow-up phone call within 3 days of discharging the patient.
Moderate
- Perform multidisciplinary discharge planning ahead of patient discharge.
- Provide patient with disease specific education, including home health referral and make follow-up appointment.
- Make a follow-up phone call within 3 days of discharging the patient.
- Provide social work referral for psychosocial assessment, if applicable.
- Review Medication Adherence and Care Gap reports for the patient in Population Intelligence.
High / Very High
- Perform multidisciplinary discharge planning ahead of patient discharge.
- Provide patients with disease specific education, including home health referral and make follow-up appointment.
- Make a follow-up phone call within 3 days of discharging this patient.
- Provide social work referral for psychosocial assessment, if applicable.
- Review Medication Adherence and Care Gap reports for the patient in Population Intelligence.
- Refer patients to pharmacy for medication review, recommendation, and patient education.
- Hold at least one interdisciplinary care conference with provider, nurses, social worker, case manager, patient, and family.