The continuum of wellbeing and disease
This flow model allows us to understand four important factors: Moving from the status quo to good long-term conditions management A dynamic response by our health system to the challenge of early recognition and good management of long-term conditions would make a major contribution to beneficial health outcomes and health outcome equality. Recognition of the disease state Recognition, as used here, describes the ability of the health system to assess the totality of risk associated with a particular disease state in an individual or whanau (rather than some symptoms), and respond from the perspective of an appropriate continuum of care rather than to a particular event (episodic care). Patients who are 'unrecognised' will flow through the system at a faster rate and with a greater loss of well being from avoidable complications. Accurately diagnosed, partially managed Even when patients are recognised the response of our health system frequently falls short of best practice recommendations, even for relatively easy to implement medications. Fully managed and participating in care With all long-term conditions patient's engagement with the problem and involvement in care is pivotal to success. Therefore system support and responsiveness to strengthen patient/whanau capability to develop and maintain a programme of self-care is essential. This requires health system approaches that support the patient and their family's role, that help mobilise community linkages and enable coordinated follow-up across multiple health providers.
The profile of population; how many people are at each stage - what is their demographic make-up, their health status, their risk profile? According to the point in the continuum, information will also include the incidence (and risk) of complications, deaths, and the demand on services.
Intervention points; are there places where it would be more effective to intervene to slow or reverse a flow?
The rate of flow; how long is it taking for people to move through from risk to more advanced disease states? What is the impact on this flow of interventions? What is the likely future demand on services?
The effect of inequalities; do particular groups have profiles and flow rates that indicate that the health system needs to respond differently to their needs?
The diagram below presents the model of disease progression in three tiers. By populating the segments of the model with actual data and identifying indicators of system performance, it becomes possible to monitor progress over time.
The aim is to slow disease progress from left to right of the continuum in the diagram. Through carefully targeted interventions to recognise and help manage those at risk of or already experiencing disease, we 'move' the population of unrecognised or poorly managed cases down toward a state of being 'fully managed and participating in care.'
Patients may be accurately diagnosed but then receive only partial management of their condition through coordination of care across services, providers and over time.
"A growing body of evidence shows that patient engagement in treatment decisions and in managing their own health care can improve patients' experience and often results in more appropriate and cost effective utilisation of health services and better health outcomes"
Coulter A. The autonomous patient. London: Nuffield Trust, 2002.
A recent World health Organisation report, Adherence to long term therapies (WHO 2003) provides a useful assessment of issues of patient involvement in chronic disease management.
"Adherence to therapies is a primary determinant of treatment success. Poor adherence attenuates optimum clinical benefits and therefore reduces the overall effectiveness of health systems."
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