Collegian
Volume 17, Issue 2 , Pages 63-69, July 2010

Can principles of the Chronic Care Model be used to improve care of the older person in the acute care sector?

  • Louise D. Hickman, RN, MPH, PhD

      Affiliations

    • School of Nursing (Sydney), PO Box 944, Broadway, New South Wales 2007, Australia
    • The University of Notre Dame Australia
    • Corresponding Author InformationCorresponding author at: School of Nursing, PO Box 944, Broadway NSW 2007, Australia. Tel.: +61 2 82044184; fax: +61 2 82044422.
    • ,
  • John X. Rolley, RN, BN(Hons)

      Affiliations

    • Centre for Cardiovascular and Chronic Care, Curtin Health Innovation Research Institute, School of Nursing and Midwifery, Faculty of Health Science, Curtin University of Technology, Australia
    • ,
  • Patricia M. Davidson, RN, BA, MEd, PhD

      Affiliations

    • Centre for Cardiovascular and Chronic Care, Curtin Health Innovation Research Institute, School of Nursing and Midwifery, Faculty of Health Science, Curtin University of Technology, Australia

Received 8 December 2009; received in revised form 11 April 2010; accepted 18 May 2010.

Article Outline

Summary 

Background

There is increasing evidence that hospitals are failing to meet the needs of older people. As a consequence acute care needs to be adapted to meet the needs of older people. Although initially developed for chronic conditions the Chronic Care Model (CCM) provides useful strategies for improving continuity and quality of care.

Method/aim

This paper describes the elements of the CCM and discusses how a chronic care approach can improve models of care delivery for older persons in the acute care hospital settings.

Discussion

The CCM provides a potentially useful approach to improve health care for older people in the acute care setting. Positive policy environments, interdisciplinary care collaboration, evidence-based practice, an emphasis on self-management strategies and empowered communities are essential elements for driving development of effective models of care.

Conclusion

Models of care require a multifaceted collaborative approach for sustainability. Implementing elements of the CCM in developing models of acute care may improve patient outcomes and decrease unnecessary admissions to hospital for older people.

Implications for practice

This paper provides suggestions for models of care to improve care of the older person in the acute care setting.

Keywords: Chronic care, Models of care, Aged care, Acute care, Nursing

 

Back to Article Outline

Background 

Globally, the population is ageing and as a consequence, people are living longer with multiple chronic conditions often requiring hospitalisation (Buchanan and Considine, 2002, Rechel et al., 2009, World Health Organisation, 2001a). In countries such as Australia, chronic illness accounts for nearly 80% of the burden of illness and injury, this burden increases with age (Australian Institute of Health and Welfare, 2008). Consequently, population ageing is placing increased demands on health care systems within Australia (Commonwealth Department of Health and Ageing, 2008) and internationally (World Health Organisation, 2001a). A range of factors, including decreased length of hospital stay and a greater focus on community based care, has led to an increasing acuity of patients admitted to acute care settings, many with complex care needs and responses to hospitalisation (Inouye, 2006). To ensure optimal health outcomes, the care of older people who are hospitalised needs to be responsive and culturally appropriate to the priorities and needs of patients and their carers (Commonwealth Department of Health and Ageing, 2008).

Often, acute hospital settings are configured to focus on acute, procedural care and do not meet the unique needs of the older person (Australian Institute of Health and Welfare, 2003). Sadly, this failure to create care models appropriate to the needs of older people has led not only to adverse health outcomes for individuals, such as hospital-acquired infections and falls, (Australian Institute of Health and Welfare, 2003, Inouye et al., 1999, Inouye et al., 2000) but also increased demands and pressures on health care systems (Australian Department of Health and Ageing, 2006). It is recognised that the focus of acute care needs to shift from reactive care and specific incidents to an integrated approach of prevention and management of chronic conditions through a planned collaborative model (Wagner et al., 2001).

This integrated approach requires health care services need to be configured to meet the needs of older persons within the acute care hospital environment with an increased focus on bridging the care gaps between the hospital and the community (Hickman, Newton, Halcomb, Chang, & Davidson, 2007). This provides a challenge for acute care providers to reconsider the manner in which they deliver care to older people, and how care meets older people's needs. In response, the New South Wales (NSW) Chronic Care program has been developed (NSW Health, 2004). This program forms part of the action plan for health, which aims to improve health care delivery, address chronic and complex diseases and their associated risk factors through the promotion of best practice. Underscoring this, the multiple co-morbid conditions experienced by older people require a planned collaborative approach to support their health outcomes as they age.

Healthcare providers in acute care need a comprehensive understanding of chronic care initiatives thereby enabling greater collaboration between community aged and acute aged care services. Ensuring that this occurs in a timely and appropriate manner requires close collaboration. Commonly acute care services are not structured to meet the care needs of older people, yet often older people remain in this setting due to the restrictions on the number of residential aged care places (Australian Institute of Health and Welfare, 2003, Australian Institute of Health and Welfare, 2008). Given that the chronic disease burden for those aged 65 years and older in Australia is anticipated to reach 80%, there is a need to strengthen capacity across all sectors of health care to improve the care of the older person (NSW Health, 2004).

Back to Article Outline

Aim 

This paper describes the elements of the Chronic Care Model (CCM) and discusses how a chronic care approach can improve models of care delivery for older persons in the acute care hospital settings.

Back to Article Outline

A chronic care approach – a potential solution for improving care of older people in hospital 

It is essential that any overarching model or framework embraces the concept of person-centred care in order to improve the continuity of care. The CCM initially developed by Wagner (Coleman et al., 2009, Epping-Jordan et al., 2004), was expanded by the World Health Organization and reframed into three levels within the health care system: (1) macro (policy and financing), (2) meso (health care organization and community) and (3) micro (patient and family) resulting in the Innovative Care for Chronic Conditions framework [ICCC] (WHO, 2002). The strength of a chronic care approach is in its framework, which demonstrates the integration of community healthcare organisations and other health care organisations. This aims to strengthen partnerships, policy, advocacy, consistent financing, and allocation of resources across sectors.

The elements that frame the discussion for this paper are the key elements of the ICCC model as can be seen in Fig. 1 below. The seven key elements are to: (1) promote policy to facilitate and support evidence-based care; (2) invest in models that coordinate care across conditions, healthcare providers, and settings; (3) provide information to patients and providers and support them in self-management; (4) promote evidence-based treatment strategies; (5) create linkages across health care providers and services; (6) empower communities and decrease stigma; and (7) monitor services and ensure that these are linked to patient outcomes. This integrated, population approach identifying the individual and their families as the focus of care, within their social context is critical in driving health care reforms and promoting effective health care transitions (Epping-Jordan et al., 2004).

Source: World Health Organization (2002). Building blocks for action innovative care for chronic conditions: Global report. World Health Organization. Used by kind permission.

Positive policy 

Healthcare delivery policy is an important consideration when developing models of care and should be seen in the broadest terms to include the persons social and community context. It therefore takes into account different influencing factors such as social support, political, economic and social factors that impact on the health outcomes of the individual (Grbich, 1996, McMurray, 2007). This point further acknowledges the contributions individuals make to their families, communities and economies (McMurray, 2007, World Health Organisation, 2001a). Recently, the Australian government has undertaken a comprehensive review of healthcare and health services in Australia. Sweeping reforms have been recommended with particular emphasis on improving the management of chronic and complex care needs (National Health and Hospitals Reform Commission, 2009). These key recommendations set the tone for further policy development particularly given the rapid population ageing faced by this nation (Commonwealth Department of Health and Ageing, 2008). Chronic conditions can be defined as conditions which develop slowly and persist for a long period of time, often for the remainder of the individual's lifetime (Bury, 1991).

Health policy making is multifaceted, politicised and complex (Nutbeam, 2003). The level of governance from which policy arises as well as the involvement of stakeholders adds to this complexity and involves international, national and local issues. Walt (2002) concludes that two main issues need to be considered in regards to effective policy implementation. Firstly, those who implement policy should be actively engaged in its development and evaluation not just those of a particular stratum of an institution; and secondly, policy development is an interactive and integrated process rather than uni-directional or linear (Walt, 2002).

Walt (2002) suggests ways to prevent disparity between formulation of policy and implementation includes involving all policy makers in policy analysis, including the development of strategies for implementation. These strategies should foresee aspects of policy from all levels such as management, technical, financial, public and government bureaucracy. For evidence-based treatment strategies to be expanded and enhanced, the acute care setting needs supportive policy in place to facilitate and support models and evidence-based care and positive health outcomes.

Invest in models that coordinate care across settings, healthcare providers, and conditions 

A chronic care approach seeks to link the community, formal healthcare settings and the individual together (Coleman et al., 2009, Wagner, 1998, Wagner et al., 2001). This framework emphasises a person-centred approach to healthcare planning and delivery where the healthcare organisation and community context are seen on a continuum. Rather than viewing the person as a passive recipient of care, the CCM focuses on the person and their family as integral members of the team engaged in continuity of care between the person's community context and healthcare providers. It is this continuity of care that is at the heart of the need for developing sustainable models of care (Wagner, 1998).

Currently, in developed countries, care is often delivered in stand-alone institutions which communicate with other settings with varying degrees of effectiveness. Continuity of care between one setting and another can frequently be problematic (Wagner, Austin, & Von Korff, 1996a). For those older people living with chronic and complex conditions, this continuity is particularly important. Strategies designed to bridge institutional barriers for the support of such patients has been found to reduce readmission due to exacerbation of disease (Coleman, Parry, Chalmers, & Min, 2006).

Models of care provide a template for replication and emulation, showing the integration of key conceptual elements (Davidson, Halcomb, Hickman, Phillips, & Graham, 2006). In recent times, models of care have received increased attention as policy makers, health professionals and consumers grapple with ways of accommodating contemporary epidemiological and management trends within systems of delivery of care that have been based on traditional principles. Models of best practice are needed to ensure the well-being of older people in the health system (NSW Health, 2006, World Health Organisation, 2001a, World Health Organisation, 2001b). Due to uncertainty in the literature, frequently the terms model of care, nursing models of care, frameworks and theory are used interchangeably, regardless of referring to varied, yet comparable concepts (Davidson et al., 2006). A model of care is described by Davidson and Elliott (2008, p. 127) as a conceptual tool that is “…a standard or example for imitation or comparison, combining concepts, belief and intent that are related in some way”. Davidson and Elliot (2001) and Davidson et al. (2006) identified nine essential critical points for the development of a model of care (Davidson & Elliot, 2008, p. 123) (see Table 1 below).

Table 1. Concepts critical to model of care development.
1. Evidence-based and/or grounded in theoretical propositions
2. Inclusive of consultation with key stakeholders
3. Based upon assessment of patient and health provider needs
4. Incorporate evaluation of health-related and intervention outcomes
5. Considerate of the safety and well-being of nurses
6. Consider the optimal and equitable utilisation of health care resources
7. Involve a multidisciplinary approach where applicable
8. Optimise equity of access for all members of society
9. Include interventions that are culturally sensitive and appropriate

Provide information to patients and providers to support them in self-management 

A chronic care approach focuses on the broader context of the person; the goal is self-management rather than affecting a ‘cure’. Riegel et al. (2009) demonstrated this in their recent scientific statement promoting self-care as a method for improving outcomes for people chronic conditions. This challenge to the prevailing paradigm of acute care means that clinicians, the older person and their carers and/or family require support to effectively bridge the acute/chronic divide. Different approaches to education are required, with greater emphasis on concordant relationships where the provider and the older person come alongside each other to support each other in the common goal of sustained outcomes. Providing information, however, goes beyond patient education as a clinical task with emphasis on teaching as a remedy for knowledge deficit (Saarmann, Daugherty, & Riegel, 2000). Patient education requires a greater emphasis on partnership between the health care providers, the patient, family/carers, general practitioners and community services. Enabling patient and carers to engage self-management forms a core outcome to a chronic care approach.

Promote evidence-based care and treatment strategies 

Effective evidence-based practice (EBP) requires the measurement of appropriate outcomes meaningful to the person, provider and healthcare system (Wagner et al., 1996a). The drive for evidence-based care delivers substantial challenges to existing healthcare paradigms. Key to the CCM and this paper is the notion that evidence-based care underpins older person-specific outcomes (Coleman et al., 2009). The model driving care should also provide the impetus for generating further evidence as well as deriving its practice policy and decisions from evidence. Generating the evidence requires engagement by the healthcare team with an informed and empowered older person (Wagner, 1998). As with all healthcare management, outcomes need to be measurable in order to provide meaningful data for evaluation (Wagner et al., 1996a).

Encouraging clinicians to engage in evidence-based practice is an ongoing issue and one gaining attention in the literature as the interface between research and translation of evidence into practice increases (Profetto-McGrath, Smith, Hugo, Taylor, & El-Hajj, 2007). For example EBP can inform what wound care products clinicians use on an older person's wound therefore effecting their health outcomes. A multidisciplinary approach is needed for access and dissemination of information and evidence. All health care providers/clinicians need to be supported by institutions to access evidence off databases, encouraged to attend important collaborative meetings so relevant information is shared and disseminated appropriately. Additionally, formal strategies are needed so new knowledge can be integrated into the care setting where required. Within the current health climate characterised by a scarcity of resources, the importance of evidence to inform decisions is increasing in the development and formulation of health policy (Dobrow, Goel, & Upshur, 2004).

Create linkages across health care providers and services 

The linkage of health care services is an essential consideration for developing effective models of care in the acute sector in order to ensure integrated and seamless care delivery is to be achieved across the continuum. A chronic care approach challenges current trends for practice and culture as it incorporates interdisciplinary care which is appropriate to the person and their community (Bodenheimer et al., 2002a, Bodenheimer et al., 2002b, Wagner et al., 2001). Improving the level of collegiality and commitment between federal, state and local government, health services and consumers is imperative for enabling transparency and improvement in continuity of care. Key stakeholders include healthcare consumers, private and public health care delivery systems, educational facilities and government organisations. The existence of institutional boundaries as a barrier to continuity of care underscores a predominant institution-focused rather than a community/person-focused care paradigm.

Empower communities 

A chronic care approach positions healthcare experience and delivery within a broad experience as the individual journeys through the experience of health and illness not in a vacuum, but rather in connection with the family, community and the broader society. Therefore, the development of models of care needs to consider these complex relationships. Delivering healthcare within a model that empowers and enables individuals, families and carers to be active participants in their health care journey is necessary (Wagner et al., 1996b, World Health Organization, 2002). Through empowering people and communities to be active in their health care journey this then can offer a sustainable way to engage them in self-management strategies and promote adherence (Rolley et al., 2008).

A person-centred care approach incorporates reciprocity between the healthcare professional and the individual where the person is the focus of the relationship and where the aim is improving healthcare outcomes. McCormack and McCance (2006, p 473) defines person-centred care as:

“…being person-centred requires the formation of therapeutic relationships between professionals, patients and their significant others, and that these relationships are built on mutual trust, understanding and sharing collective knowledge”.

Whittmore (2000) agrees that person-centred care increases knowledge, which can allow for better clinical decision-making and optimal interventions. In addition, Stewart et al. (2000) identified a positive relationship between a person-centred care approach and improved health status of patients, while also identifying a reduction in referrals and diagnostic tests in their observational cohort study. In practical terms, McCormack and McCance (2006) describe four pre-requisites for person-centred care: the attributes of the clinician, the environment or situation in which care is delivered, the processes in place to enable person-centred care, such as a focus on the delivery of care through activities, and expected outcomes. Given the variability in the health care system, implementation and development of chronic care initiatives which centres on consumer involvement in healthcare decision-making is a priority (Australian Institute of Health and Welfare, 2002, NSW Health, 2003, Wagner et al., 2001).

Monitor service provision and quality and link these to patient outcomes 

This integrated, population approach identifying the individual and their family as the focus of care, within their social context is critical in driving health care reforms and promoting effective health care transitions (Epping-Jordan et al., 2004). Any proposed change has to be sustainable. Sustainable long-term change should be the goal of changes to models of care. The elements of a chronic care approach presented in this paper are integral to achieving this outcome. Resource utilisation, collaboration, process-orientated approaches to ongoing development, broad stakeholder involvement, flexibility, and person-centred approaches are hallmarks of sustainability.

Back to Article Outline

Sustainability of affirmative health care practices 

Although the literature is replete with accounts of the challenges in caring for older people in the acute care system, solutions are less evident. Further integrated and interdisciplinary research into ageing is needed and is important for considering how research outcomes will be implemented and proposed changes sustained. Extraneous forces including workforce resource and fiscal constraints, burgeoning chronicity and globalisation will compound these efforts. The challenge, therefore of protecting health in this time of rapid change involves understanding both the large and small representations that make up health care. McMurray (2007) describes this as follows:

“Contemporary definitions of health acknowledge the connectivity between people and the environment in two ways: first, health is dynamic rather than static and second, the environment or context of people's lives influences the extent to which they can reach their health potential”(McMurray, 2007, p13).

Communities are therefore ecological (Trickett, 1984). As such, the community gives to the people, and the relationships of people within the community give back to the community with mutual benefit (McMurray, 2007). Sustainable health then is the ability to act in response to health deficits within communities using the health resources necessary (McMurray, 2007). Key factors identified in promoting sustainability of favourable change in the clinical setting are: clinical leadership capacity building, involvement of key stakeholders, evidenced-based practice, use of change management strategies, promotion of organisational change, quality improvement practices, participation in clinical governance, best practice guidelines informed by research evidence, and community engagement (Barnett and Barnett, 2001, Davidson and Elliot, 2008, Davidson et al., 2006, McMurray, 2007).

Back to Article Outline

Conclusion 

Implementing elements of the Chronic Care Model in developing models of acute care may improve patient outcomes and decrease unnecessary admissions to hospital for older people. Models of care to improve care of the older person in the acute care setting provide a multifaceted collaborative approach for sustainability. Improving the connectivity between key stakeholders such as all levels of government, health consumers, private and public health care delivery systems and educational facilities is imperative to achieve health care reform. With the ageing of the patient population and rapidly changing health system demands, developing effective models of care will assist these changes and promote consistency across the care continuum.

Back to Article Outline

References 

  1. Australian Department of Health and Ageing . Department of Health and Ageing Factbook 2006. Canberra: Commonwealth of Australia; 2006;
  2. Australian Institute of Health and Welfare . Older Australia at a glance. 3rd ed.. Canberra: Australian Institute of Health and Welfare; 2002;
  3. Australian Institute of Health and Welfare . Interface between hospital and residential aged care. Feasibility study on linking hospital morbidity and residential aged care data. Canberra: Australian Institute of Health and Welfare; 2003;
  4. Australian Institute of Health and Welfare. (2008). Australia's health 2008: The eleventh biennial health report of the Australian Institute of Health and Welfare. Retrieved 14 March 2009, from http://www.aihw.gov.au/publications/aus/ah08/ah08-c00.pdf.
  5. Barnett P, Barnett R. Community ventures in rural health: The establishment of community health trusts in southern New Zealand. Australian Journal of Rural Health. 2001;9:229–234
  6. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. Journal of American Medical Association. 2002;288(14):1775–1779
  7. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: The Chronic Care Model, Part 2. Journal of American Medical Association. 2002;288(15):1909–1914
  8. Buchanan J, Considine G. Stop telling us to cope! A report for the NSW Nurses Association. Sydney: Australian Centre for Industrial Relations Research and Training, University of Sydney; 2002;
  9. Bury M. The sociology of chronic illness: A review of research and prospects. Sociology of Health and Illness. 1991;13(4):451–468
  10. Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: Results of a randomized controlled trial. Archives Internal Medicine. 2006;166(17):1822–1828
  11. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Affairs. 2009;28(1):75–85
  12. Commonwealth Department of Health and Ageing. (2008). Ageing and aged care in Australia. Canberra; Commonwealth of Australia.
  13. Davidson PM, Elliot D. Managing approaches to nursing care delivery. In:  Chang E,  Daly J editor. Transitions in nursing. Sydney: Churchill Livington Elsevier; 2001;
  14. Davidson PM, Elliot D. Managing approaches to nursing care delivery. In:  Chang E,  Daly J editor. Transitions in nursing. 2nd ed.. Sydney: Churchill livington Elsevier; 2008;
  15. Davidson PM, Halcomb E, Hickman L, Phillips J, Graham B. Beyond the rhetoric: What do we mean by a ‘model of care’?. Australian Journal of Advanced Nursing. 2006;23(3):47–55
  16. Dobrow M, Goel V, Upshur R. Evidence-based health policy: Context and utilisation. Social Science and Medicine. 2004;58:207–217
  17. Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH. Improving the quality of health care for chronic conditions. Quality and Safety in Health Care. 2004;13(4):299–305
  18. Grbich C. Health in Australia: Sociological concepts and issues. Sydney: Prentice Hall Health; 1996;
  19. Hickman L, Newton P, Halcomb EJ, Chang E, Davidson PM. Best practice interventions to improve the management of older people in acute care settings: A literature review. Journal of Advanced Nursing. 2007;60(2):113–126
  20. Inouye SK. Delirium in older persons. New England Journal of Medicine. 2006;354(11):1157–1165
  21. Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine. 1999;340(9):669–676
  22. Inouye SK, Bogardus STJ, Baker TL, Leo-Summers L. The hospital elder life program: A model of care to prevent cognitive and functional decline in older hospitalized patients. Journal of the American Geriatrics Society. 2000;48:1697–1706
  23. McCormack B, McCance T. Development of a framework for person-centred nursing. Journal of Advanced Nursing. 2006;56(5):472–479
  24. McMurray A. Community health and wellness: A socio-ecological approach. 3rd ed.. Sydney: Mosby Elsevier; 2007;
  25. National Health and Hospitals Reform Commission. (2009). A healthier future for all Australians – Final report of the National Health and Hospitals Reform Commission. Canberra: National Health and Medical Research Council.
  26. NSW Health. (2003). NSW Chronic and Complex Care Programs: Progress report for program activity to 30 September 2002. Sydney: NSW Health.
  27. NSW Health. (2004). Strengthening capacity for chronic care in the NSW Health System, report on phase one. Executive summary. Chronic care program. Action plan for health. Sydney: NSW Department of Health.
  28. NSW Health. (2006). First report on the models of care project February–April 2005. Sydney: NSW Department of Health.
  29. Nutbeam D. How does evidence influence public health policy? Tackling health inequalities in England. Health Promotion Journal of Australia. 2003;14(3):154–158
  30. Profetto-McGrath J, Smith KB, Hugo K, Taylor M, El-Hajj H. Clinical nurse specialists use of evidence in practice: A pilot study. Worldviews on Evidence-based Nursing. 2007;4(2):86–96
  31. Rechel B, Doyle Y, Grundy E, McKee M. How can health systems respond to population ageing?. Copenhagen: World Health Organization; 2009;
  32. Riegel B, Moser DK, Anker SD, Appel LJ, Dunbar SB, Grady KL, et al. State of the science: Promoting self-care in persons with heart failure: A scientific statement from the American Heart Association. Circulation. 2009;120(12):1141–1163
  33. Rolley JX, Davidson PM, Dennison CR, Ong A, Everett B, Salamonson Y. Medication adherence self-report instruments: Implications for practice and research. Journal of Cardiovascular Nursing. 2008;23(6):497–505
  34. Saarmann L, Daugherty J, Riegel B. Patient teaching to promote behavioral change. Nursing Outlook. 2000;48(6):281–287
  35. Stewart M, Brown J, Donner A, Mc Whinney I, Oates J, Weston W, et al. The impact of patient-centered care on outcomes. The Journal of Family Practice. 2000;49(9):796–804
  36. Trickett EJ. Toward a distinctive community psychology: An ecological metaphor for the conduct of community research and the nature of training. American Journal of Community Psychology. 1984;12(3):261–279
  37. Wagner E. What will it take to improve care for chronic illness?. Effective Clinical Practice. 1998;1:2–4
  38. Wagner E, Austin B, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: Translating evidence into action. Health Affairs. 2001;20(6):64–78
  39. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. In:  Fox PD,  Fama T editor. Managed care and chronic illness: Challenges and opportunities.. Gaithersburg, MD: Aspen; 1996;
  40. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Millbank Quarterly. 1996;74(4):511–543
  41. Walt W. Health policy: An introduction to process and power. London: Zed Books; 2002;
  42. Whittmore R. Consequences of “Not knowing the patient”. Clinical Nurse Specialist. 2000;14:75–81
  43. World Health Organisation. (2001a). Global movement for active ageing – background information. Retrieved April 14, 2003, from www.who.int/hpr/globalmovement/background.htm.
  44. World Health Organisation. (2001b). Department of Noncommunicable Disease Prevention and Health Promotion (NPH) Global Movement for Active Ageing – Initiatives. Retrieved April 14, 2003, from www.who.int/hrp/globalmovement/initiatives.htm.
  45. World Health Organization. (2002). Building blocks for action Innovative Care for Chronic Conditions: Global report. 2002.

PII: S1322-7696(10)00035-1

doi:10.1016/j.colegn.2010.05.004

Collegian
Volume 17, Issue 2 , Pages 63-69, July 2010

Article Tools

* Image Usage & Resolution