Improving Chronic Care in America: From Disease-Care to Real Health Care
Improving Chronic Care in America
Introduction
Almost half of all Americans live with a chronic condition.1,2 Further complicating that statistic is approximately half of those suffering from a chronic condition have comorbities.1,2 The public health initiative Chronic Care Model, found at www.improvingchroniccare.org suggests, and I agree, that our current health care system is “reactive,” and is as Dr. Andrew Weil states, a “disease-care” rather than a true health care system.2,3
My Story
I was a mere two years into my studies as an undergraduate in athletic training, more than 22 years ago, when I first felt the absence of a “holistic” or patient-centered focus in health care. Working in a busy, high-strung Division I sports medicine department, everything was highly geared toward speedily “fixing only what was broken.” There was little to no emphasis, and absolutely no coursework available, in injury and disease prevention and proactive lifestyle counseling.
Flashback to 17 years ago, and I found the same to be true when I was working on my masters in physical therapy at UNC Chapel Hill. Don’t get me wrong, I love UNC School of Medicine and Division of Physical Therapy. In fact, I am now working on my doctorate at UNC. But UNC taught me that part of our duty as lifelong learners, and to the practice of medicine, is to always search for the better way.
As a result of my frustration with the lack of a preventive, holistic focus, instead of dropping out of PT school, I instead asked for special permission to cross over into the School of Public Health and take graduate level independent study coursework while finishing my master’s in the division of physical therapy. The request was granted, and I was ecstatic. I did get my proverbial cake and got to eat it too.
I have never looked back since then, or been happier with that professional decision. I have been able to realize, through combining my experience in public health, physical therapy, and integrative medicine, my original goal I set some 22 years ago. That goal was to provide compassionate, partnership-based care through community-based educational programs that offer preventive care, continuity of care, and patient empowerment through digital media activism and my day-to-day clinical practice.
What’s more, the work I do now is creatively evidence-based, combining the art and science of yoga with physical therapy. I love my work.
Proposal for Evidence in Motion
The CDC and APTA alike recognize the potential role of physical therapy in physical health promotion, disease mitigation, and injury prevention throughout the lifespan with the well-established relationship between a sedentary lifestyle and chronic disease.4,5 Yet, little has changed in the role of physical therapists during my 22 year educational and clinical career.
Early on in my career I mobilized my community by organizing free and low-cost health promotion and injury prevention workshops and classes in eastern North Carolina. I find being a kind of “community organizer” is a very cost-effective and clinically effective means for patient counseling, education, and intervention. Workshops I have conducted in my area from 1999- present include: low back pain prevention and management, nutritional considerations for longevity, yoga for runners, yoga for low back pain, yoga for youth, Pilates for adults, chair yoga for the older population, prenatal yoga, and yoga for women’s health, among many others.
On studying the World Health Organization’s strategies for evaluating health promotion efficacy, the following principles have underscored my historical efforts for health promotion. They include “empowerment and participation of the individual while including holistic treatment (biopsychosocial), interdisciplinary, equitable (social justice), sustainable, and multistrategy principles.6
Four principles should be considered in planning and evaluating health promotion programs6:
1 Participation of the community
2 Evaluation from multiple disciplines
3. Evaluation to enable “individuals, communities, organizations, and governments to address important health promotion concerns.”
4. Evaluation that is “appropriate and can accommodate the complex nature of health promotion interventions and their long-term impact.”
Case In Point – Shifting from Disease-Care to Health Care for Low Back Pain
More than 84% of Americans will experience back pain in their lifetime, making the back pain the most common reason for seeking care, behind the common cold.10,11,12 That means most of us will, at some point, have low back pain, making it perhaps the most common orthopaedic chronic condition in America today. Additionally, several studies report that the majority of treatment for low back pain is not based on solid science. Which means when you visit your doctor you are NOT likely to get evidence-based care. This is disturbing, but can be changed if the public was better informed about what science actually says helps low back pain. Physical therapy is well supported in the literature to provide the best outcomes and reduce the cost and likelihood that you will experience chronic back pain. However, only 20% (at most) patients ever make it to see a physical therapist.9 What is needed is a campaign to educate folks on the best care practices of low back pain.
A review of the literature revealed that back pain mass media campaigns as a primary means to alter back pain beliefs are inadequate and requires “concomitant strategies” to effect lasting change.7 Campaigns in Australia, Scotland, Norway, and Canada like “Back Pain: Don’t Take It Lying Down,” and other multi-million dollar campaigns used TV commercials, celebrities, comedians, clinical experts, and other spokespeople to try and improve public knowledge about the cause and management of back pain.7 Their failure, in part, is attributed to a myopic focus on health promotion via a single variable. Success, however, may be attainable if “supportive laws, health public policy, and social marketing endeavors” are included in future campaigns.7
What this means is that we need better social policy and supportive legislation that would decrease barriers to people receiving scientifically supported care for back pain. In more than two decades of professional practice I wholeheartedly support these recommendations. I am foremost an advocate for my patients and community to get the best health care possible.
Through experiential efforts, I have found that my involvement as an author and blogger/social media have done more to affect change in my patients and local community than I could have affected just seeing a single patient at a time, in traditional practice. I still see patients on a regular basis, yet fully half of my 22 years has been spent in writing about and advocating for patients via multi-media platforms. I have produced videos, DVD’s, workshops, and have written for local newspapers and magazines for my patient populations; and I remain in constant “keyboard-ready position” writing and teaching graduate and post-graduate/CE’s in health promotion and injury and disease prevention using a biopsychosocial model.
Empowering the public about informed back pain care and facilitating belief reinforcement that is congruent with current evidence-based guidelines for back pain care is paramount8; and until this happens, the cost and disability of back pain, perpetuating myopic “disease-care,” will continue to increase in the United States.
References
1. Partnership for Solutions: Johns Hopkins University, Baltimore, MD for The Robert Wood Johnson Foundation (September 2004 Update). “Chronic Conditions: Making the Case for Ongoing Care”.
2. Improving Chronic Care.org. Group Health Research Institute.http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 Last accessed September 20, 2013.
3. Weil, Andrew. US Manages Disease, Not Health. Special to CNN.http://www.cnn.com/2013/03/08/opinion/weil-health-care/index.html Last accessed September 20, 2013.
4. Centers for Disease Control and Prevention. Life Stages and Specific Populations. Role of physical therapy in physical health promotion, disease mitigation, and injury prevention by life stage: age-related health risk by chronologic age. Available at: http://www.cdc.gov/LifeStages/. Last accessed September 20, 2013.
5. Sullivan KJ, Wallace JG,Jr, O’Neil ME, et al. A vision for society: Physical therapy as partners in the national health agenda. Phys Ther. 2011;91(11):1664-1672. doi: 10.2522/ptj.20100347; 10.2522/ptj.20100347.
6. World Health Organization. Regional Publications. Evaluation in Health Promotion: Perspectives and Principles. European Series, no. 92. 2001.
7. Gross DP, Deshpande S, Werner EL, Reneman MF, Miciak MA, Buchbinder R. Fostering change in back pain beliefs and behaviors: When public education is not enough. Spine J. 2012;12(11):979-988. doi: 10.1016/j.spinee.2012.09.001; 10.1016/j.spinee.2012.09.001.
8. Zusman M. Belief reinforcement: One reason why costs for low back pain have not decreased. J Multidiscip Healthc. 2013;6:197-204. doi: 10.2147/JMDH.S44117; 10.2147/JMDH.S44117.
9. Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening Trends in the Management and Treatment of Back Pain. JAMA Intern Med. 2013;():-. doi:10.1001/jamainternmed.2013.8992
10. Freburger, PT, PhD et al. ; The Rising Prevalence of Chronic Low Back Pain. Arch Intern Med. 2009;169(3):251-258.
11. Carey, T MD, MPH; Freburger JK PT, PhD; Holmes GM PhD; Castel, L PhD; Darter Jane BS; Aganst R. PhD; Kalsbeek W. PhD; Jackman Anne MSW. A Long Way To Go: Practice Patterns and Evidence in Chronic Low Back Pain Care. Spine. 1 April 2009 – Volume 34 – Issue 7; pp 718-724.
12. Balague F et al 2012. Non-specific low back pain. Lancet. Feb 4;379(9814)
