How can chronic disease management programmes operate across care settings and providers?

Key messages

• Chronic diseases affect all countries, and the increase in their prevalence is largely attributable to changing demographics, increased life expectancy, changing lifestyles, better disease management and treatment and a better understanding of the factors that cause poor health and disease.
• In the WHO European Region, 86% of deaths are attributable to chronic diseases. With 50–80% of all global health spending related to chronic diseases, health systems that maintain current disease management practices cannot afford to continue caring for the escalating numbers of people with chronic diseases.
• Chronic disease management is a systematic approach to coordinating health care interventions across levels (individual, organizational, local and national), and good evidence indicates that such coordination across care settings and providers is more effective than single or uncoordinated interventions.
• Policy options to manage chronic diseases can be pursued via different avenues but can be broadly divided into individual, health delivery systems and system-wide approaches. Interventions in European countries generally focus on specific diseases rather than determinants and are often insufficiently coordinated.
• Interventions such as ranking people according to their risk, multidisciplinary teams and supporting self-management have potential but only if policies, structures and financial and other incentives support people in working together.
• There is no correct approach to chronic disease management. Evidence throughout the world suggests that, to be successful, policy-makers should consider:
• • providing strong leadership and vision at the national, regional or organizational level;
  • ensuring robust collection of information and data-sharing among all stakeholders;
  • providing care based on people’s needs and an ability to identify people with different levels of need;
  • targeting key risk factors, including widespread disease prevention initiatives;
  • supporting self-management and empowering people with chronic diseases; and
  • involving a wide range of stakeholders such as individuals, the voluntary and community sector, clinicians, private industry and public services.