A diagnosis of arthritis-associated pain or disability is a frequent reason for a primary care visit. Even when not the chief concern, arthritis is present as a comorbid condition in approximately 50% of older adults with other commonly occurring chronic conditions, including COPD, diabetes, and cardiovascular disease. A significant challenge for health care systems, managing these conditions effectively requires addressing both medical needs and barriers that impact health and healthy outcomes. In this article, we introduce the newly developed Public Health Framework for Collaborative Arthritis Management and Wellbeing and describe a current pilot project in which we are evaluating the framework’s feasibility and effectiveness. Key elements of this framework are the incorporation of a new infrastructure entity, the community-care hub (CCH), and the use of this entity to deliver care focused on health-related social needs and arthritis-appropriate, evidence-based interventions (AAEBIs). A CCH is a community-based organization that centralizes and coordinates the delivery of social care needs as well as evidence-based interventions. CCHs may contract with health systems and payers to direct resources to the community to address health-related social needs, including food, housing, transportation, and supports for health and medical concerns. CCHs also employ navigators or community health workers who work with referrals from health care providers to support patients’ social and health needs and provide individualized care coordination. Emerging as a powerful tool for the coordination of health and social care, CCHs are central to the 2023 U.S. Department of Health and Human Services call to action to address unmet health-related social needs.

The prevailing evidence for arthritis management recommends both pharmacologic and non-pharmacologic care, including physical activity and biopsychosocial considerations such as the health-related social needs that CCHs address. The U.S. Centers for Disease Control and Prevention (CDC) public health guidance for adults with arthritis follows the adult physical activity guidelines and recommends at least 150 minutes of moderate-intensity aerobic activity weekly to help reduce pain, improve function, and delay the onset of functional loss. Increasing the proportion of adults with arthritis counseled by their medical teams regarding physical activity is one of the key Healthy People 2030 objectives to achieve the goal of reducing overall rates of pain and disability from arthritis. Given the higher level of prescribed opioid use among adults with arthritis compared to those without this diagnosis, the opportunity to engage in a care model that addresses health-related social needs, physical activity, and self-management could be attractive to primary care physicians and their patients.

Starting in 2021, the National Association of Chronic Disease Directors (NACDD) in partnership with the CDC developed a care model for adults with osteoarthritis. Initial efforts focused on a landscape assessment that identified key considerations and barriers to creating an evidence-informed approach for physical activity screening, counseling, and referral to arthritis-appropriate, evidence-based interventions (AAEBI). The AAEBIs are physical activity and self-management education programs that undergo a criterion-based review process to ultimately improve arthritis-related pain, physical function, and quality of life. Unfortunately, patients and primary care providers are often unaware these programs exist and are available in their communities. To develop the care model, we convened a panel of experts who were engaged in a human-centered design process. The result is the following framework, aimed at improving the quality of life for adults with arthritis and other comorbid conditions.

Figure 1. The Public Health Framework for Collaborative Arthritis Management and Wellbeing 

The Framework

Figure 1 depicts the first draft of the Public Health Framework for Collaborative Arthritis Management and Wellbeing. This collaborative care model is set within the public health system and incorporates key public health principles such as disease screening, self-management of chronic conditions, and community engagement. The left side (blue) elaborates on the functions of the primary care setting. The right side (green) details the functions of the community-care hub (CCH). The center of the model incorporates care elements that may not be accessed by all patients but which may play a specific and crucial role for individuals who have more functional loss, including referrals to physical and occupational therapy, orthopedics or other relevant specialists, and/or community health workers. A core strength of the framework lies in its collaborative and bi-directional nature. It depicts a closed-loop system where communication among all care providers is central. This coordination highlights the need for a comprehensive care approach for patients with chronic conditions such as osteoarthritis.

In this framework, primary care providers start by identifying adults with osteoarthritis using the American College of Rheumatology clinical classification criteria. They then rely on the public health approach of Screening, Brief Intervention and Referral to Treatment (SBIRT), as advocated by Exercise is Medicine^® for health care providers. Screening tools include the physical activity vital sign, patient-reported outcome measures such as the PROMIS physical function and pain interference instruments, and a fall risk assessment using the STEADI screening tool. Based on screening results, providers then offer the patient brief advice and recommendations for physical activity and self-management to help improve their condition. This is a key component, as a health provider’s advice is associated with high adherence to such recommendations. The provider then makes a referral to the CCH team, which works with the patient to identify an appropriate AAEBI or activity for them to participate in. Additionally, patients who require specialty or rehabilitative care receive referrals as outlined in the center of the framework (see Figure 1).

Once a referral is received, the CCH contacts the patient and conducts a screening to determine any barriers to healthy outcomes. They engage the patient in a shared decision-making process to identify and connect the patient to programs and resources aimed at addressing their health and social needs. For patients with arthritis, this may involve helping them find transportation to programming and then enrolling in a community-based AAEBI. Throughout this process, information is shared by the Hub to the patient's health provider through a secure, closed-loop communication system. While still evolving, we anticipate that the infrastructure and technology needed to facilitate seamless communication between CCHs and primary care will continue to improve over the next few years.

The Pilot Project

The National Association of Chronic Disease Directors is leading efforts to assess the framework’s feasibility through an ongoing pilot project. This pilot pairs the CCH Iowa Community HUB with a local federally qualified health center (FQHC). Working with an FQHC ensures a health equity and preventive care lens for the pilot, as FQHCs specialize in serving underserved communities and emphasize preventative care. We are developing technology solutions for referral and communication, establishing data sharing agreements, and clarifying the evaluation criteria to determine the framework's feasibility and effectiveness.

Conclusion

The Public Health Framework for Collaborative Arthritis Management and Wellbeing, piloted through the collaboration between a primary care setting and a CCH, holds significant promise as a model for improving chronic disease management. By leveraging the strengths of both settings, this framework has the potential to:

• Enhance access to appropriate resources: Patients with arthritis or other chronic diseases will benefit from improved access to evidence-based physical activity and self-management programs offered by community hubs, while primary care providers gain support in managing complex chronic conditions.
• Improve patient outcomes: Through a focus on factors that impact health outcomes and collaborative care, the framework can potentially lead to improved pain management, physical function, and overall quality of life for adults with arthritis.
• Streamline communication and referral: Technology solutions can facilitate seamless communication and referral between primary care and CCHs, improving care coordination and reducing patient burden.

By fostering collaboration and addressing both medical and social needs, this innovative framework can pave the way for a more comprehensive and effective approach to managing arthritis. As we gather evidence and refine the framework through the pilot project, the potential for broader implementation for other chronic conditions is increasingly clear. This collaborative public health approach, centered on patient needs and leveraging community resources, holds promise for improving chronic disease management on a larger scale.

About the authors

Julia Chevan, PT, PhD, MPH is Senior Program Manager on the Arthritis portfolio with the National Association of Chronic Disease Directors where she is leading efforts on a pilot project to increase health provider referrals to evidence-based programs.
 
Lisa Erck, MS is a public health and worksite wellness consultant with the National Association of Chronic Disease Directors and is part of the Arthritis portfolio.  Lisa provides support to state arthritis prevention programs and is a Master Trainer for the CDC Work@Health program.
 
Heather Murphy is a public health consultant with the National Association of Chronic Disease Directors where she is part of the Arthritis portfolio.  Heather has over 20 years of experience working in chronic disease prevention both at the state and national levels.

**Feature photo obtained with a standard license on Shutterstock.