nearly 55 million by 2020, and more than 70 million by 2030 (CMS, 2009; IOM, 1978, 1987, 2001; Salsberg and Grover, 2006; Shea et al., 2008; U.S. Census Bureau, 2004; Wenger et al., 2003; Wolff et al., 2002). Many older persons, especially the “oldest old,” have chronic conditions and disability, so as the population of older Americans expands, the absolute number with chronic conditions and disability will also rise. Unless scientists make unprecedented breakthroughs in preventing or curing chronic conditions soon, the United States will face growing pandemics of chronic disease and disability throughout the next several decades.
America’s providers of health care and supportive services have not yet developed the capacity to provide high-quality, comprehensive chronic care. Its hospitals, nursing homes, physicians, clinics, and community-based service agencies still operate as uncoordinated “silos” (IOM, 2001), much of the physician workforce is inadequately trained in chronic care (Salsberg and Grover, 2006), and the quality and efficiency of chronic care remain “far from optimal” (IOM, 2001; Salsberg and Grover, 2006; Wenger et al., 2003). In a recent study of health care in seven developed nations, the United States was first (by far) in health care spending but sixth in the quality of care and last in care efficiency, equity, and access (tie). The United States was also last in enabling long, healthy, productive lives for its citizens (Davis et al., 2010).
A successful, long-term, population-based approach to reducing the prevalence and the consequences of chronic illness in the United States would include (a) the primary prevention of chronic diseases, (b) secondary prevention by screening and treatment of preclinical chronic conditions, and (c) tertiary prevention of disability and suffering by effectively treating chronic conditions that are already clinically manifest. Primary preventive initiatives might seek to reduce the incidence of chronic conditions by altering social, cultural, and environmental influences on the population’s diet, physical activity, and exposure to toxins (e.g., tobacco) and infection (e.g., HIV/AIDS). Secondary and tertiary preventive initiatives would seek to treat chronic diseases promptly and effectively through the coordinated efforts of multiple health care providers and community-based supportive services. The ultimate goal of this paper is to identify opportunities for public health agencies to promote such coordination of “medical” and “social” resources to limit the functional and quality of life consequences often borne by Americans with chronic conditions.
Two overlapping conceptual models help to explicate the complex interacting factors that must be addressed to control the effects of chronic disease in the U.S. population. Not only does the Chronic Care Model (Bodenheimer et al., 2002) focus mostly on improving the ability of the health care delivery system (and its patients and families) to treat chronic illnesses, but it also acknowledges the importance of integrating the delivery