Integrated Disease Management

Comprehensive integrated care, self-care, patient support and education, training for healthcare workers to improve the quality of care: This team works to facilitate and support the strengthening of the capacity and competencies of the health system for the integrated management of chronic noncommunicable diseases (CNCDs) and their risk factors. These functions are among the core elements of the CARMEN Network and the Regional Strategy for Chronic Disease Prevention and Control. The team follows the Chronic Care Model, as described below. Also click below for a list of relevant documentation and resolutions.

Documentation | By Topic | Resolutions

The current acute health care model has not proven effective in dealing with prevention and management of chronic conditions. Successful chronic disease programs require an intersectoral approach and a reorientation of the healthcare system. It is necessary to improve the accessibility and availability of services and access to essential medicines and to have multidisciplinary health teams with the appropriate skill mix delivering services. Emphasis is needed on quality of care to reduce barriers related to social, economic, and cultural factors and to improve social protection for health, particularly among vulnerable populations.

In order to face these challenges, PAHO's action plan considers that prevention and management of chronic diseases requires integration through strengthened referrals and relationships among primary, secondary, and tertiary levels of care. The entire spectrum of disease management from prevention to screening and early detection, diagnosis, treatment, self-care, rehabilitation, and palliative care is necessary. 

Chronic Care Model

The constructs of the Chronic Care Model1 shown above are incorporated into the objective for the management of chronic diseases and risk factors, and are aimed at improving outcomes in five main areas:

  • A coherent approach to system improvement.
  • Development and adherence to guidelines.
  • Self-management support for people with chronic diseases.
  • Improved clinical information systems.
  • Appropriate skill mix and improved technical competency of the health work force, including cultural competence and sensitivity.

This plan also considers technical assistance for chronic disease programs, the reorientation of health services towards chronic diseases, and improved access to essential medicines and technologies.

PAHO's strategy recognizes the call for a renewed approach to primary health care and the highest attainable level of health for everyone as emphasized in the Regional Declaration on the New Orientations for Primary Health Care (promulgated at the 46th Directing Council). Also reflected in this plan is Resolution CD45.R7: Access to Medicines, which prioritizes access to medicine and other health supplies.

Documentation

By topic

PAHO/WHO Resolutions Related to Integrated CNCD Managment

1 Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality Improvement in Cronic Illness Care. A Collaborative Approach. J Quality Improvement 2001;27(2):63-80.
Last Updated ( Monday, 07 May 2012 )