Chronic Disease Management Model

Chronic illness is increasingly taking shape of every part of the health provision aspects in Saudi Arabia. This kind of menace is mostly affecting the elderly and the young people of the nation. It calls for leadership in the health sector to come up clearly and implement some of the chronic care models to reduce the negative effect of chronic diseases on the general population of the nation. Citing this problem, there is an increase in momentum to align the health sector. This involves scientific, administrative and clinical structures of Saudi Arabian health care (Fisher, 2008). This also includes building up of mental health services. In 2001, the health system developed a New Health System that was effective in the 21st century. The aim was to create a system that improves service delivery while reducing preventable errors together with the costs involved. It enabled to get support for development and assessment of new integrated health systems with the aim of providing quality health services. Different governmental organizations, research organizations and philanthropic establishments made several proof-of-concept trials of an integrated health process for medical and mental healthcare (Rittenhouse, Shortell & Fisher, 2009).

They indentified Patient-centered Medical Home Model as the key for integrating healthcare services with an aim of improving access of the services by the citizens (Fisher, 2008). This paper looks at factors, which contribute to better performance, implication for providers, consumers and the general performance of the system. It also highlights the equity implications and opportunities for future improvements.

Description of the Model

This model came into existence in 1960s when the pediatricians were struggling to coordinate multifaceted care services for children who had a chronic illness. They gave guidelines that each child should have a record that is centralized. They also identified that physicians should identify the centrality by the use of records in the care delivery systems and other health service providers (Graf, 2009). They included families that could utilize the model in the course of their service delivery. World Health Organization had a great effect on the development of the home model. It extended medical home from integrated repository of health service information to heuristic model. It consolidates multiple resources of health for individuals and communities through continuous associations with the primary health providers in the nation.

This model coordinates healthcare services through a team that provides primary health care. The home medical model was named by Saudi Arabia as a framework for primary healthcare provision, which utilizes the knowledge of the providers in a unique way. It also identified that the framework makes utility of patient’s resources and needs to promote an organized treatment and prevention plan in partnership with patients (Shortell & Casalino, 2008) Chronic care model, which was developed alongside with patient-centered medical home forms the modern ideas of the medical home. When the pediatrics was struggling with the complexity of chronic illness, internists identified that clients with chronic diseases could benefit an integrated and proactive for delivering services. They developed CCM a body that highlight main interfaces between communities, health systems, health management information, patients and infrastructure required to improve efficiency and quality any chronic disease care. The developments in the definition of this model together with its major components indicate a widening interest in integrated healthcare for chronic and complex diseases management. It also increases acceptance of the model’s potentiality to develop the idea that systems that provide integrated, efficient and empathic interface for clients could improve efficiency and quality of healthcare services (Shortell, Casalino & Fisher, 2010).

Elements of PCMH Contributing to better performance

Patient-centered Medical home is a strategy that provides the health care givers with styles and variations to handle chronic illness in Saudi Arabia. It enables the physician team to offer whole episodes of care, and personalized services to individual patient. This is supported by several organizations in Saudi and other worldwide organization. The model has four main elements that make it identical form others (Eggleston et al., 2009). The four elements include; emphasizing patients to be at the core of their operations, practicing of the new model together with associating the increased incentive payment for providing coordinated healthcare services. Any population group of patients it gets access to the healthcare provider who may be an assistant to the physician or a nurse who is a practitioner (Rittenhouse et al., 2008). In this contest, first hand care to patients is a guarantee to all group members. This model acknowledges the fact that patients are the important members of the healthcare system. The model empowers all clients and their families to become active participants in the service provision process. It also enables the service providers to collaborate with clients to identify, address and understand the preferences and desires of the clients.

The new model incorporates registries of all disease management and health electronic records. It also supports programs that enable patients to support themselves while continuously improving initiatives (Friedberg, 2009). The tool helps the model to track down all the patient referrals, information concerning service providers, and treatments given to the patient.

The model takes a very crucial responsibility thus requires to get some payments as it carries out its operations. Therefore, it receives a care coordination fee. It is also eligible for payments from pay-performance programs to support the organization to undertake responsibilities of the organization. It shares in savings that come from providing healthcare for less established target expenditures.

Success of the Model

Earlier research indicated that the model has great success in Saudi Arabia. The success involved providing quality health services to patients, coordination of the healthcare services provided to the patients and making the services easily accessible by patients (Dorr et al., 2008). If the services are compared to other, models it is quite clear that PCMH has grater advantages than any other model. It is true from the research that it managed to reduce both hospitalization and emergency visits in the rooms. The results were achieved at a relatively cheaper cost compared to the previous methods that were in use. For instance, the use of quasi-experimental format, investigators in Saudi Arabia found that there were twenty-nine percent fewer patient cases in emergency rooms. There were eleven percent fewer cases in ambulance healthcare services than in other models. When compared with the site controls. It gives high patient experience and a few staff burnouts.

The study reveals that befits came in without any increase in the costs. The model is quite effective in the most sections of healthcare services across Saudi Arabia where it serves more than three hundred and eighty thousand people in the Group Health Cooperative System. Another example comes from the northern part of Saudi where the model managed to get forty percent reduction of asthma hospitalization and eleven percent fewer cases involving emergency visits in the rooms (Daar et al., 2007). The nations’ State Children Health Insurance Program was able to save around $135 and four hundred million pounds. This model involves more than one thousand three hundred sites based on community practice. It also has more than four thousand five hundred primary health providers in the nation. This model can be the most effective when it comes to economically suitable model. It has saved Saudi Arabia from huge expenses in the healthcare provision. It encourages other healthcare providers to join hand together for the betterment of the patients this include private integrated healthcare providers. They coordinate and care for all patients resulting to a fourteen percent decreasing hospitalization of patients in the country. There was also a decrease of nine percent in the cost over twenty-four months. The extended savings came from a return on investment (Steiner, 2008).

Weaknesses of the Model

There are several evidences that support the success of PCMH model in Saudi Arabia. Despite all evidences, there are some points that indicate the weak points of the system in service delivery. Current research show that few practices in Saudi Arabia can qualify to be among the PCMH model. The index measuring reveals that out of twenty in the PCMH, only seven can fit to be in the model. It is true that elements of medical home start increasing in practices that involve around 65 physicians. It also gives an overview that 140 physicians can only complete half of the set elements in their practices (Grumbach et al., 2009). Therefore, minor practices that comprise of many providers in Saudi Arabia will need considerable support. They will also require technical assistance to be a full functioning organization. Current physicians cannot use the elements as they are in the model without amending them to suit their functions and practices. They ought to make changes in the structure during the delivery period, patient outreach and management of the diseases in the patients since they are always far away from them. Examples of structural changes that can be reshuffled include long periods for visiting patients, paring of physicians and their assistants or nurse practitioners (Casalino et al., 2003).

The other way is to establish email connection with clients. Point of caring involves promotion of phone and email visits, chat reviews planning visits and pre-visits. The other option is to create health maintenance reminders within the electronic system (Reid, 2009). This will help to remind the care providers on every step to undertake when time arrives. Some of the patient outreach operations that need changes include, medication promoting self-management projects and medication follow-ups. Management must also receive drastic changes to consider the use of rapid process cycles together with salaries that compensate physicians adequately (Wagner et al., 2001).

Opportunities for improvement

The advances are taking place through different sectors. For instance, it is taking discourse in political and academic sectors. There is an increase in focusing on the duty of home medicals in providing psychiatric care. The Arabian medical providers and pediatrics understood that the system require efficient, adoptive and effective patient-centered care. In the same way, the psychiatrists have followed the same footsteps to recognize that the present environment in health reform has an opportunity to advance and refresh the delivery process of the psychiatric services through including principles from home medical in Saudi Arabia (Mehrotra, Epstein & Rosenthal, 2006).

This is a chance for making improvement in the system delivery but needs careful deliberation on the heterogeneity of the population who gets access to the mental healthcare scheme. This involves stratifying clients requirements based on the severity of their psychiatric illness and medical requirements. It is important to develop all these in the integrated care forms (Beaulieu et al., 2006). This is because the interface between psychiatric illness and medical is a complex issue. There are four quadrants to observe well known as Four Quadrant Clinical Integration Model. It illustrates four populations. Population group I has a population with low severity of psychiatric illness and medical requirement. The second population quadrant has low severity of medical illness and high severity psychiatric diseases. Quadrant three population has low psychiatric illness and high medical requirements while the fourth quadrant has high severity medical illness and high psychiatric illness. The form does not clearly describe psychiatric diagnoses, which are of high severity, it comprises of population with persistent and severe mental illness (SPMI) (Tollen, 2008). It includes all the population living with schizoaffective disorder, bipolar I disorder and schizophrenia.


Chronic illness is a great challenge to most of the nations in the world. The health providers are the key members who support all programs that are work towards reduction of chronic illness in different nations. To help in combating this menace, there are several models that help the physicians and all the practitioners with guidelines on how to carry themselves during the process. For instances, the PCMH is one of the methods that can help a nation like Saudi Arabia to achieve better results in patient care through using less resources compared to other modes such as Accountable Care Organization and Population Health Management (Eggleston, et al. (2009).

Every model has its own advantages and disadvantage. For the PCMH as applied to (Gillies, 2006). Saudi Arabia, it has proved to work through by giving more benefits than negative effects. It has made that country reduce the cost of service delivery to the minimum required levels. Since this model includes patient interests, it is the most important to offer quality services to the communities with great chronic diseases. The effectiveness of this model is far much better than the other two models.


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