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7 The Call for Action Maintaining or enhancing quality of life for individuals living with chronic illnesses has not been given the attention it deserves by health care funders, health systems, policy makers, and public health programs and agencies. The social, economic, and functional impact of chronic illnesses on these individuals is not precisely or critically monitored in populations. Also, although many control programs exist for some of these conditions, they are not well evaluated, for either efficacy or population coverage. As the United States faces difficult economic times, the epidemic of chronic illness is increasing for many reasons: the aging of the adult population, as in other developed countries; the far from complete primary prevention of important illnesses, even when feasible; inadequate evidence on how to conduct effective public programs and interventions; inadequate public programmatic resources, even for effective, evidence-based programs; in- adequate attention to chronic illness management by clinical health services charged with managing patients with chronic illnesses; and the failure to more effectively align clinical and public health services where synergies might be gained (Alliance for Health Reform, 2011). The chronic disease epidemic is steadily moving toward crisis proportions, and it is a global problem. This has been well documented, as a recent comprehensive study finds that noncommunicable diseases will cost the global economy $47 tril- lion by 2030 (Bloom et al., 2011). This report addresses the following important areas: 257

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258 LIVING WELL WITH CHRONIC ILLNESS • The economic consequences of chronic illnesses to individuals, families, the health care system, and the nation; • The development and incorporation of conceptual models, cre- ated by the committee, as well as borrowing from the Centers for Disease Control and Prevention and sources, to provide a more detailed framework for the overall discussion and the major issues, including public health disease control, economics, and both clini- cal and public health interventions; • A concerted approach to understanding the dimensions of preven- tion as they relate to chronic disease control in the community; • A wide spectrum of chronic diseases, their clinical stages, their pat- terns and anticipated course, the common or cross-cutting burden and consequences of living with chronic illness, the populations that experience chronic illnesses disproportionately, the effect of comorbidity, and the adverse effects of clinical treatment. Ap- pendix A, on depression and chronic medical illness, supports this discussion; • A set of exemplar diseases, health conditions, and impairments for consideration to advance the next generation of chronic disease management programs from a public health perspective, with an explanation of the difficulties in determining a set of diseases that should be the focus for public health action; • A detailed account of how to improve surveillance in order to better assess health-related quality of life and to plan, develop, implement, and evaluate public health policies, programs, and interventions relevant for individuals living with chronic illness; • A discussion of the role of public health and community-based interventions for chronic disease management and control, along with examples and designation of venues in which evidence-based effective programs could be located. This discussion is supported by Appendix B, on new models of community-based care for peo- ple with chronic illness; • A consideration of the importance of federal policy in enhancing chronic disease control, including an emphasis on the Affordable Care Act and related legislation, as well as exploring the Health in All Policies and the Health Impact Assessment approach, and how the execution of these laws and policies can be used to enhance public health strategies to improve living with chronic illness; and • An assessment of the critical role of aligning public health and non–health care community organizations as a system change to better control chronic diseases and improve quality of life and health outcomes in patients living with them.

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259 THE CALL TO ACTION The overall goal of this report is to highlight the toll of all chronic illnesses on living well from a population health perspective; to discuss the deficits in chronic disease control; and to make recommendations to improve public health efforts to help individuals live better with chronic illness. However, there are many domains of chronic disease management from a public health perspective for which there is simply not enough research or program evaluations to draw definitive conclusions or make concrete recommendations. The committee examined and addressed several important dimensions of the difficulty of controlling chronic disease and makes recommendations on how to proceed. However, much more remains to be done. The committee provided seventeen recommendations without priority order or measured ranking, as all of them are believed to be equally important strategies and steps to undergird public health action to help individuals living with chronic illnesses. Government public health agencies have the ability to take action to help people live better with chronic illness. They have the expertise to assess a public health problem, develop an appropriate program or policy, and en- sure that programs and policies are effectively delivered and implemented. It is difficult, however, for state and local public health agencies to plan, develop, implement, evaluate, or sustain programs, policies, and strategies to manage and control chronic diseases when they are structurally deficient and lack the capacity at the system level to effectively take action. The availability of sufficient resources to fortify the operational infrastructure of government public health agencies is not abundant. Given the serious state of the U.S. economy, infrastructure difficulties, and the need to maximize the impact of public health efforts related to living well with chronic illness, the committee’s recommendations are intended to respond to the statement of task, optimize efforts to better understand the burden and needs of people living with chronic illness, promote the creation and implementation of public health policies an emerging legislation, improve the dissemination of effective community-based interventions, improve preventive clinical guidelines for people with chronic illness, and promote the testing of an aligned health system to help people live well with chronic illness. We think that this report and the recommendations are rooted in a population-based approach and underscore the special attention needed and the importance of public health action and leadership in the management and control of chronic disease in support of living well.

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260 LIVING WELL WITH CHRONIC ILLNESS REFERENCES Alliance for Health Reform. 2011. Preventing Chronic Disease: The New Public Health. Washington, DC: Alliance for Health Reform. http://www.allhealth.org/publications/ Public_health/Preventing_Chronic_Disease_New_Public_Health_108.pdf (accessed De- cember 18, 2011). Bloom, D.E., E.T. Cafiero, E. Jané-Llopis, S. Abrahams-Gessel, L.R. Bloom, S. Fathima, A.B. Feigl, T. Gaziano, M. Mowafi, A. Pandya, K. Prettner, L. Rosenberg, B. Seligman, A. Stein, and C. Weinstein. 2011. The Global Economic Burden of Non-communicable Diseases. Geneva: World Economic Forum.