14.2 Chronic Disease Model, Care Plans & AASM Clinical Practice Guidelines
Key Takeaways
The Chronic Care Model links community resources, health system support, self-management support, delivery system design, decision support and clinical information systems to produce informed patients and prepared teams.
Metabolic syndrome is diagnosed when 3 of 5 criteria are present: large waist, high triglycerides, low HDL, blood pressure ≥130/85 and fasting glucose ≥100 mg/dL.
AASM guidelines use GRADE: 'We recommend' signals a strong recommendation and 'We suggest' a conditional one.
The CCSH exam handbook says that when RECOMMENDED is bolded in an item, the answer should follow universally recommended guidelines such as AASM practice parameters.
The AASM's 2021 guidance statement suggests against routine repeat sleep testing in asymptomatic patients doing well on PAP, but supports testing after non-PAP treatments or when symptoms persist.
14.2 Chronic Disease Model, Care Plans & AASM Clinical Practice Guidelines
Domain 2, Task D asks the CCSH to develop individualized patient care plans using the chronic disease model (e.g., morbid obesity, metabolic syndrome) and following clinical practice guidelines. The care coordination section shows what a care plan contains; this section explains the model behind it and the guidelines it follows.
Sleep Disorders as Chronic Diseases
OSA, insomnia, narcolepsy and RLS are usually lifelong or long-lasting. Like diabetes or hypertension, they need ongoing self-management, regular follow-up, adjustment over time and attention to related conditions. Treating OSA as a one-time "machine delivery" leads to high abandonment.
The Chronic Care Model
The Chronic Care Model (Wagner and colleagues) describes six elements that together produce productive interactions between an informed, activated patient and a prepared, proactive practice team:
| Element | What it looks like in a sleep program |
|---|---|
| Health system organization | Leadership support and incentives for long-term sleep care, not just testing volume |
| Community resources | A.W.A.K.E. groups, weight-management programs, employer wellness, transportation help |
| Self-management support | Goal setting, action plans, PAP apps, sleep diaries, problem-solving skills |
| Delivery system design | Defined team roles (CCSH navigator, physician, DME, dentist), planned follow-up visits, group visits |
| Decision support | Evidence-based guidelines and protocols built into workflows |
| Clinical information systems | Registries, telemonitoring dashboards, reminders, outcome reports |
Obesity and Metabolic Syndrome
Obesity is the strongest modifiable risk factor for OSA. BMI classes are: overweight 25.0–29.9, class I obesity 30.0–34.9, class II 35.0–39.9, and class III 40 or higher (older texts call class III "morbid obesity").
Metabolic syndrome is present when at least 3 of 5 criteria are met (harmonized definition):
- Elevated waist circumference (in the U.S., commonly 102 cm or more in men and 88 cm or more in women)
- Triglycerides of 150 mg/dL or higher (or on treatment)
- HDL cholesterol below 40 mg/dL in men or below 50 mg/dL in women (or on treatment)
- Blood pressure of 130/85 mmHg or higher (or on treatment)
- Fasting glucose of 100 mg/dL or higher (or on treatment)
OSA and metabolic syndrome cluster together and reinforce each other through intermittent hypoxia, sympathetic activation and sleep loss. CPAP alone usually does not cause weight loss, so weight management needs its own plan: nutrition and activity support, anti-obesity medications (tirzepatide is FDA-approved for moderate-to-severe OSA with obesity), and bariatric surgery referral when appropriate. The CCSH coordinates these referrals and keeps the sleep plan aligned with them, including repeat testing after major weight loss.
Building the Individualized Plan
A chronic-disease care plan:
- starts from the patient's goals and readiness (see motivational interviewing);
- sets SMART goals (specific, measurable, achievable, relevant, time-bound), such as "use CPAP at least 6 hours on 6 nights a week for the next month";
- lists interventions, education, team roles and follow-up dates;
- includes measures (adherence, ESS, FOSQ, weight, blood pressure); and
- is reviewed and revised at each visit.
Following Clinical Practice Guidelines
How AASM Guidelines Are Graded
AASM guidelines use the GRADE method. A strong recommendation ("We recommend…") is one clinicians should follow under most circumstances. A conditional recommendation ("We suggest…") is one clinicians should offer to most patients when clinically appropriate, with shared decision-making. Good practice statements describe steps that are clearly beneficial without formal grading.
Important
The CCSH candidate handbook says that when RECOMMENDED is bolded in an exam item, the best answer follows universally recommended guidelines and industry standards, such as AASM practice parameters.
Key AASM Guidelines for CCSH Practice
| Topic (year) | Core messages |
|---|---|
| Diagnostic testing for adult OSA (2017) | PSG or technically adequate HSAT for uncomplicated adults at high risk; PSG for significant comorbidities; questionnaires alone must not be used to diagnose |
| PAP treatment of adult OSA (2019) | PAP for OSA with sleepiness (strong); CPAP or APAP for ongoing use; education at initiation; telemonitoring and behavioral support suggested |
| Oral appliances (2015, with AADSM) | Custom, titratable appliances for adults who cannot tolerate or prefer an alternative to CPAP; follow-up testing |
| Surgical referral (2021) | Discuss surgical referral for adults with BMI under 40 who cannot use PAP; bariatric referral for BMI 35 or higher |
| Longitudinal management of OSA (2021 clinical guidance statement) | Suggests follow-up PSG or HSAT to assess non-PAP treatments (such as oral appliances or surgery) and when symptoms persist despite PAP; suggests against routine retesting in patients who are doing well on PAP |
| Behavioral treatment of insomnia (2021) | Multicomponent CBT-I strongly recommended; sleep hygiene alone suggested against |
| Pharmacologic treatment of insomnia (2017) | Weak recommendations for specific agents; against trazodone, diphenhydramine, melatonin and valerian |
| Circadian rhythm disorders (2015) | Timed melatonin and light therapy for specific disorders |
| Central hypersomnolence (2021) | Strong recommendations for modafinil, pitolisant, sodium oxybate and solriamfetol in narcolepsy |
| RLS and PLMD (2024) | Iron studies and iron therapy; alpha-2-delta ligands first; against standard use of dopamine agonists |
| REM sleep behavior disorder (2023) | Conditional recommendations including melatonin and clonazepam |
| Central sleep apnea (2025) | Conditional options including CPAP, bilevel with backup rate, ASV (with caution in reduced ejection fraction), oxygen, acetazolamide and phrenic nerve stimulation |
| Actigraphy (2018) | Recommended for circadian disorders and insomnia assessment |
Putting Guidelines Into Practice
Guidelines become useful when they are built into protocols, order sets, decision support and education materials. The CCSH helps by keeping patient materials consistent with current guidance, flagging when a plan departs from it, and documenting shared decisions when a patient chooses a conditional option.
An AASM guideline statement begins, 'The AASM suggests that clinicians use…' How should this be interpreted?
It is a strong recommendation that clinicians must follow for every patient without exception
It is a conditional recommendation to offer to most patients, using shared decision-making
It is a statement that the option is harmful and should never be offered to patients
It is a non-binding opinion with no supporting evidence review behind it at all
A man has a waist circumference of 110 cm, triglycerides of 180 mg/dL, HDL of 38 mg/dL, blood pressure of 124/78 mmHg and fasting glucose of 92 mg/dL. Does the patient meet criteria for metabolic syndrome?
No, because blood pressure must always be elevated for the diagnosis
Yes, because 3 of the 5 criteria are met (waist, triglycerides and HDL)
No, because at least 4 of the 5 criteria are required for the diagnosis
Yes, because any single abnormal value is enough to make the diagnosis
A patient with moderate OSA has used CPAP for 3 years with excellent adherence, a low residual AHI and no symptoms. She asks whether she needs a repeat sleep study each year. What does AASM guidance suggest?
Every PAP user must have a repeat in-lab study every year to keep insurance coverage active
Repeat testing is required whenever the PAP device is replaced, regardless of symptoms
Routine retesting is not suggested for patients doing well on PAP; testing is for new or persistent symptoms
Repeat testing is only needed for patients who switch from a nasal mask to a full face mask, regardless of symptoms
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