The Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai recognizes that chronic diseases are the leading cause of death and disability worldwide, including in the United States. We have partnered with Teva Pharmaceuticals to develop novel programs to help vulnerable persons with one or more chronic conditions to self-manage their health with peer support.
This initiative is increasingly important as more adults over 65, and increasingly younger persons, live with more than one chronic condition. Globally, approximately 42 percent of adults have multiple chronic conditions. But among those over age 65, the figure may be 80 percent or higher. In general, the diseases involved are chronic. Our projects with Teva focus on helping control these conditions in vulnerable populations by preventing hospitalization and emergency department visits and helping patients self-manage their health.
The Arnhold Institute-Teva collaboration has developed projects in two locations as well as a software tool (MCCTool) for data analysis. The projects operate in East Harlem in New York City and Navrongo, Ghana. The goal is to develop effective and scalable methods to identify the most vulnerable chronic disease patients and ensure their access to medications, treatments, and knowledge to control their conditions.
Program Sites
Both of these programs focus on treating chronic diseases that occur simultaneously, by combining behavior counseling and primary care. Both are led by volunteers, peer counselors, nurses and other non-doctors.
We recognize that the COVID-19 pandemic is a grave threat to patients who live with underlying chronic diseases. We are adapting both initiatives to respond: by educating and empowering patients to avoid infection and by using the internet and telephone to make care and counseling virtual whenever possible.
The program locations are:
New York City: We work with the PeakHealth Clinic at The Mount Sinai Hospital, which targets patients with multiple chronic conditions and frequent inpatient admissions for intensive outpatient care and social support.
In collaboration with leaders at PeakHealth, we built and implemented a 12-week intervention, the PeakHealth Wellness Program, to help patients diagnosed with multiple chronic conditions support each other to achieve better health outcomes. With a strong focus on peer leadership, participants benefited from this additional informational and emotional support as well as mutual reciprocity on shared medical issues.
The PeakHealth Wellness Program is co-led by trained peer leaders, some Peak Health patients, and professional topic experts. Topics include healthy eating, medication adherence, communicating with your doctor and care team, and managing stress and chronic pain. Expert counselors include a pharmacist, a clinical pain management physician, an internal medicine physician, social workers, and care coordinators.
Following the success of this pilot initiative, we are expanding the program in 2020 to include 100 to 200 patients from PeakHealth and other high-risk clinics at Mount Sinai. We are incorporating COVID-19 content and transitioning the program to an online platform.
Navrongo, Ghana: In collaboration with the Navrongo Health Research Centre, which has designed and built innovative primary care models in Ghana for more than 30 years, we are developing a care program that leverages local nurses and volunteers to treat high blood pressure, depression, and other chronic diseases in this rural, low-income area. Navrongo developed the nationwide the Community-Based Health Planning and Services (CHPS) program, which sends nurses and volunteers door-to-door to provide vaccines and care. The CHPS Program has saved the lives of thousands of children.
In 2020, chronic diseases threaten to surpass childhood infection as a leading cause of death. Therefore, we are training CHPS providers to treat these conditions, backed up by peer support from community volunteers.
In both locations, our work involves four phases:
Discovery: Identify populations most severely impacted by multiple chronic conditions. Explore feasible, evidence-based strategies to protect and maintain their health.
Pilot Intervention: Develop and pilot test these strategies, measuring their effect on changes in behavior, including adherence to medication protocols and decreased use of emergency rooms and hospital admissions.
Scale Services: Refine, scale, and evaluate the pilot evaluation data to develop and enhance the services.
Sustainability: Integrate a scaled model within local and regional health systems to ensure their cost-effective continuation and expansion.
Program Tools
In addition to developing site-based programs, we have developed a series of tools that can be used, adapted, and shared, free of charge, by health care workers in a variety of settings. These include a data analysis tool and a program development and management toolkit.
Multiple Chronic Conditions Tool for Health Care Analytics: This analytic tool, also called MCCTool, enables users to identify patterns in the cost and prevalence of multiple chronic conditions. Specifically, it can help users determine which segments of a given population have specific multiple chronic conditions, analyze these data without assumptions, and sort it by prevalence and attributed spending of multiple chronic conditions. The tool runs on Python 3.6.7. and is open access. It has enabled Arnhold to quantify the association of socioeconomic status with the development of a second chronic condition. We found that patients living in lower-income areas developed a second chronic condition approximately 15 years earlier on average than their higher-income counterparts, often by age 35. This tool can help health system and clinic managers to track how diseases cluster in their own populations.
Peer-Supported Self-Management of Chronic Disease: A Toolkit
Based both on our PeakHealth Wellness pilot program and principles of implementation science, this toolkit aims to enable health care teams to build and adapt a peer-led self-management program for patients with multiple chronic conditions based on the PeakHealth Wellness Program model. The toolkit is designed for program planners and managers, peer leaders, and participants. It provides information on developing service provision methods, program review processes, and data collection for later analysis.
The toolkit also includes a downloadable asset library of digital materials to support local development and implementation of other chronic disease peer support programs across diverse settings. Geared toward program planners, peer leaders, and participants, it encompasses checklists, handouts, and worksheet files that are easy to modify for the programs’ specific contexts and needs. All materials are designed to help readers develop, adapt, and implement a peer-led self-management program for patients with multiple chronic conditions.