Toward an Ecosystemic Approach to Chronic Care Design and Practice in Primary Care

Nothing is new under the sun. It is very helpful that the Wagner model(1) has gained so much publicity and traction, and Soubhi’s article(2) reawakens our attention, as they serve to refocus our vision back on the nature of our own discipline. The concept of care for health, illness and disease in an empowered community and ‘ecosystem’ is, in fact, the theoretical basis for Primary Health Care.(3)

Caring for the individual in their experience of illness, and enabling their interactions with the medical/health system(4) within the context of family and community engagement(5) is, and has long been, a subject of vital and practical interest to governments,(6) and family physician(7,8,9). Particularly, it has been identified, that there is a need for reflection on the delicate balancing of our role and functions in relation to disease and illness for individuals in our care, their families, the community and the health system.(10,11,12) There is a wealth of existing literature internationally about chronic illness(13) and community empowerment: “People’s ability to act through collective participation strengthening their organizational capacities, and challenging power inequities leads to achieving improved outcomes. Empowerment is a complex strategy that sits within complex environments.”(14)

We need to continue to reflect and act on the vast knowledge base that exists within and outside of our discipline, and in particular, we need to think deeply about changes to our conceptual frameworks and principles.(15) Our recent research has synthesized some of this knowledge within a muli-layered complex adaptive system framework demonstrating how health and illness co-exist and evolve.(16)

Complex systems provide a framework for an expanded knowledge base, debate and discussion of reforms and development of PHC goals and strategies. However, interventions in complex (adaptive) community ‘ecosystems’ are fraught with the risks of unintended consequences;(17) many of which can be prevented by using more appropriate approaches and analysis, and understanding and building on our history.

1. Wagner EH, Groves T. Care for chronic diseases. BMJ. 2002;325 (7370):913–914

2. Soubhi H. Toward an ecosystemic approach to chronic care design and practice in primary care.Ann Fam Med. 2007 May-Jun;5(3):263-9.

3. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September. 1978. www.who.int/hpr/NPH/docs/declaration_almaata.pdf

4. Martin C. Chronic illness care in General Practice – the practitioner-patient relationship. Chapter 5. In Walker C, Peterson C, Millman N, Martin C. (Editors) Chronic Disease: new perspectives and new directions. Tertiary Press, Melbourne Publication May 2003.

5. Kaufman T. Community Engagement: A key principle in Primary Health Care. Insights from 35 years of management of the CLSC and community health care sector. Key Note Presentation . Best practice workshop. Responding to community needs. Health Canada, Sept. 26/2006 Halifax, N.S.

6. Pan American Health Organization/World Health Organization. Regional Declaration on the New Orientations for Primary Health Care. (Declaration Of Montevideo) Pan American Health Organization/World Health Organization 46th Directing Council 57th Session of the Regional Committee. Sept 25th, 2005.

7. Mcwhinney IR. A Textbook of Family Medicine.- 2nd Edition. Oxford University Press 1981, 1989, 1997. New York.

8. Sturmberg J. with a contribution by C Martin. The Foundations of Primary Care. Daring to be Different. Oxford San Francisco: Radcliffe Medical Press, 2007.

9. Rosenberg C. The Tyranny of Diagnosis: Specific Entities and Individual Experience. Milbank Quarterly 2002;80(2):237-260.

10. Martin C. The Care of Chronic Illness in General Practice. PhD, Australian National University, 1999.

11. Martin C and Nisa M. Meeting the needs of children and families in chronic disease and illness. A greater role for the GP? Australian Family Physician August 1996.

12. Martin C, Chronic Disease and Illness Care: Additional Principles of Family Medicine are needed to address ongoing health system redesign. Canadian Family Physician (in press) 2007.

13. Walker C. Recognising the changing boundaries of illness in defining terms of chronic illness: a prelude to understanding the changing needs of people with chronic illness. Australian Health Review 2001;24(2):207-214.

14. Wallerstein N (2006). What is the evidence on effectiveness of empowerment to improve health? Copenhagen, WHO Regional Office for Europe (Health Evidence Network report; http://www.euro.who.int/Document/E88086.pdf, accessed 01 February 2006).

15. Martin CM, Kaufman T. Addressing Unfinished Business in Primary Health Care (PHC). A Shared Framework across Canada is needed to implement PAHO/WHO ‘new orientations’ for adaptive PHC-based health systems. A Commissioned Report for the Canadian Alliance of Community Health Centre Associations; Primary Health CareTransition Fund (PHCTF) National Evaluation Strategy.January 2007.

16. Sturmberg,J. Martin C and Moes M. Appreciating Individual ‘Health’ from a complexity perspective Informing practice and policy. NAPCRG poster presentation 2005.

17. Institute Of Medicine: Unintended Consequences of Health Policy Programs and Policies: Workshop Summary. http://www.iom.edu/Default.aspx?id=5089

Competing interests:   None declared

Congratulations. A most stimulating paper that hopefully will start ongoing discussions about patient care as a complex adaptive process around illness.

Physicians as well as health care bureaucrats and reformers should carefully consider the use of the term illness rather than disease (1, 2) – illness referring to the multidimensional subjective experience of health disturbances (and thus making health care and health care reform open to complexity approaches) whereas disease refers to the objective patho-physiology of an underlying condition (and thus is static and reductionist).

Secondly Soubbi refers to sense-making as part of the illness experience. The origins of this notion go back to 1986 when Uexküll and Pauli argued for the introduction of the notion of bio-semiotics as the mode to understanding the health/illness/disease experience.(3) Reflection on this concept led us to propose the somato-psycho-socio-semiotic model of health where health is seen as a balance between the somatic (or biological), social, emotional and cognitive components of once life experience.(1) The somato-psycho-socio-semiotic model of health represents a complex adaptive metaphor that clearly puts patients and their experiences in the centre of the health care endeavour.

This shift in conceptualisation not only re-focuses on the business of medicine – improving the patient’s health experience, it also should foster a reflective debate on the impacts of the disease-management philosophy of the last few decades.(4)

References

1. Sturmberg J. The Foundations of Primary Care. Daring to be Different. Oxford San Francisco: Radcliffe Medical Press, 2007.

2. Bentzen N. WONCA Dictionary of General/Family Practice. Copenhagen: Månedsskrift for Praktisk Lægegerning, 2003.

3. Uexküll Tv, Pauli H. The mind-body problem in medicine. Advances: Journal of the Institute for the Advancement of Health 1986;3:158-174.

4. Rosenberg C. The Tyranny of Diagnosis: Specific Entities and Individual Experience. Milbank Quarterly 2002;80(2):237-260.

Competing interests:   None declared

In his essay, Dr Soubhi argues for an ecosystemic understanding of chronic care founded on a communal and a dynamic view of the response of the patient, family, and health professionals to chronic illness. Based on a communal view that integrates the skills and resources of all the participants, the author’s recommendations for clinical practice include: “ask not only what you can do for your patients but also what the patients and families can do for themselves and for your clinical practice” and “elicit and foster participation”.(1) The ecosystemic approach invites to empowerment philosophy…

The individual empowerment model takes a holistic and patient-centred approach, and considers that the patient has the right and the responsibility to take decisions concerning his health.(2) An abundant literature confirms that interventions based on empowerment are associated with good outcomes (3) such as a more effective decision-making, a better management of disease complications and adoption of healthier behaviours.(4) As healthcare professionals, we can help patients with chronic diseases gain more power over their lives by stressing their capacities instead of their weaknesses, and helping them find their own solutions.(5)

In our empowerment efforts, we have to take into account the dynamic view of chronic care (1) and adapt our accompaniment to patients’ changing needs. Changing needs often imply the development of new capacities and the redefinition of old solutions. So in light of the ecosystemic approach and the empowerment philosophy, another recommendation could be added for clinical practice: “Help patients gain more power over their lives while keeping in mind their changing needs”.

1. Soubhi H. Toward an ecosystemic approach to chronic care design and practice in primary care. Ann Fam Med. 2007;5:263-9.

2. Feste C. A practical look at patient empowerment. Diabetes Care. 1992;15:922-25.

3. WHO. World Health Organization. Innovative Care for Chronic Conditions. Building blocks for action. http://www.who.int/diabetesactiononline/about/icccglobalreport.pdf. Accessed June 6, 2007.

4. WHO. World Health Organization. Europe. What is the evidence on effectiveness of empowerment to improve health ? http://www.euro.who.int/Document/E88086.pdf. Accessed June 6, 2007.

5. Lord J, McKillop Farlow D. Une étude sur l’habilitation: répercussions sur la promotion de la santé. Promotion de la santé. 1990;29:2-8.

Competing interests:   None declared

The ecosystemic approach presented by professor Soubhi represents certainly an ideal to follow.(1) It underlines the need for team work in primary care to give better care for patients with chronic conditions. Patients and family members appear essential partners in this team. This is directly in line with the Chronic Care Model.(2) One of the problems is that family doctors do not always have access to a team to help patients get through the process of illness. Many family doctors work in isolation and the healthcare system does not provide them with enough support. In this situation, comprehensive care might have limitations and the pressure to deliver disease focused care is high.

In primary care, single chronic disease is a rare event and multimorbidity is the rule rather than the exception.(3) Multimorbidity that is recognized in the paper presented by professor Soubhi may become a real challenge or even an impediment to the delivery of such comprehensive care. Multimorbidity brings a great deal of problems that further complicate care delivery: competing demands, competing guidelines, different levels of interaction and so on. In these circumstances family doctors often act as firefighters if they are not adequately supported by a team of other primary healthcare professionals.

The shift to an ecosystemic approach would certainly require a complete rethinking and reengineering of the healthcare system. The move from an “ethos of standardization and prefabricated structures to a streaming and tracking ethos” means more money to invest in an already costly healthcare system. There are also major implications for training. A cultural change cannot be achieved without paying the price.

(1) Soubhi H. Toward an ecosystemic approach to chronic care design and practice in primary care. Ann Fam Med 2007;5(3):263-269.

(2) Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: translating evidence into action. Health Aff (Millwood) 2001;20(6):64-78.

(3) Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005;3(3):223-228.

Competing interests:   None declared