An Adaptive, Contextual, Technology‐Aided Support (ACTS) System for Chronic Illness Self‐Management

摘要

Policy Points Fundamental changes are needed in how complex chronic illness conditions are conceptualized and managed. Health management plans for chronic illness need to be integrated, adaptive, contextual, technology aided, patient driven, and designed to address the multilevel social environment of patients’ lives. Such primary care–based health management plans are feasible today but will be even more effective and sustainable if supported by systems thinking, technological advances, and policies that create and reinforce home, work, and health care collaborations. Context The current health care system is failing patients with chronic illness, especially those with complex comorbid conditions and social determinants of health challenges. The current system combined with unsustainable health care costs, lack of support for primary care in the United States, and aging demographics create a frightening probable future. Methods Recent developments, including integrated behavioral health, community resources to address social determinants, population health infrastructure, patient‐centered digital‐health self‐management support, and complexity science have the potential to help address these alarming trends. This article describes, first, the opportunity to integrate these trends and, second, a proposal for an integrated, patient‐directed, adaptive, contextual, and technology‐aided support (ACTS) system, based on a patient's life context and home/primary care/work‐setting “support triangle.” Findings None of these encouraging trends is a panacea, and although most have been described previously, they have not been integrated. Here we discuss an example of integration using these components and how our proposed model (termed My Own Health Report) can be applied, along with its strengths, limitations, implications, and opportunities for practice, policy, and research. Conclusions This ACTS system builds on and extends the current chronic illness management approaches. It is feasible today and can produce even more dramatic improvements in the future.