chronic care challenges: people, places, and principles · –hospital –nursing home. depression....
TRANSCRIPT
Chronic Care Challenges:People, Places, and Principles
David B. Reuben, MDArchstone Foundation Chair and
ProfessorDavid Geffen School of Medicine
at UCLA
Outline of next 15 minutes
• Population-based health care needs• Physicians roles in coordinating care• Meeting population-based health needs• Framework and principles for successful
models
Population-based Health Care
• Who are the elderly Americans?– Not sick + chronic diseases– Sick, functionally impaired
Population-based Health Care
• Who are the elderly Americans?– Not sick + chronic diseases– Sick, functionally impaired– At the end of life
Population-based Health Care
• Where do the elderly Americans receive their health care?– Community– Hospital– Nursing home
Depression
SickFunctional Impairment
Multiple Chronic Diseases
Not SickFunctionally Intact+ Chronic Diseases
Dementia Diabetes
Specific Diseases
Hospital Nursing Home
End-of-Life
Community
OFFICE
Inside Healthcare PCP Outside Healthcare
Patient/Family
$•Coverage
•Other physicians
•Lab/Tech
•Home Health
•Hospice
•ED
•Pharmacy
•Insurers
$
•Community services
•Support groups
•Living facilities
•Governmental agencies
HOSPITAL OFFICE
$Patient/Family
Physicians
•Hospitalists/Coverage•Other Physicians
PCP
Nursing
Discharge Planning
OFFICE
PCP
NURSING HOME
Patient/Family
Physicians•SNFists•Coverage•Other Physicians
Nursing
Discharge Planning
$
HOSPITAL OFFICE NURSING HOME
PCPPatient/Family Patient/Family
Inside Healthcare Outside Healthcare
Physicians
Nursing
Discharge Planning
Physicians
Nursing
Discharge Planning
$ $
$
Patient/Family
Meeting Population-based Health Needs
• Building systems for caring for patients– Not sick + chronic diseases– Sick, functionally impaired– End of life care
• Managing patient transitions between settings
• Redesigning providers’ roles
Not Sick + Chronic Diseases
• Preventive and Episodic Care – Preventive care is as comprehensive
and inexpensively as possible– Patient trust in the health care system
rather than the individual provider– High caliber, convenient, prompt,
episodic care is available
Not Sick + Chronic Diseases
• Chronic disease care– Team care: who, when, by whom?– Identifiable physician in the team– Disease management strategies– Self-management skills– Shared decision-making
Sick, Functionally Impaired
• Redesigning hospital and nursing home care • Care management-team care
– Disease management and patient management
• Physician intimately involved• Active discussions about prognosis, quality
of life, and preferences for care
End-of Life Care
• Begin process early• Trust between provider and patient• Information sharing
– prognostic– quality of life
• Symptom management• “Polished” end of life care
Managing Patient Transitions Between Settings
• Flow of clinical information between settings• Seamless care shared among different
providers• Ongoing re-evaluation of goals
The Roles of Providers
• Physician’s role will differ based on patient needs– May not be the first or primary contact
• Delegation of responsibilities• Re-examination of scopes of practice
– What’s in a title?– Working to highest level of competency
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Functional and Clinical Outcomes
Self-Management
Support
Health System
Resources and Policies
Community Organization of Health Care
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Chronic Care Model
Six Guiding Principles for Geriatric Health Care Delivery
1. Care must be personalized to meet each patient’s goals, values, and resources
2. Care should be provided in accordance with best practices
3. It takes a team to provide the best care