organizing care for patients with chronic diseases darren a. dewalt, md, mph associate professor...

Organizing Care for Patients with Chronic Diseases

Darren A. DeWalt, MD, MPHAssociate Professor

University of North Carolina

Living with chronic illness is like piloting a small plane

icic.org

To get safely to their destination, pilots need

Self-Management Support

Effective Clinical Management

Treatment Plan

Close Follow-up

Flight instruction

Preventive Maintenance

Safe Flight Plan

Air Traffic Control Surveillance

icic.org

Usual care works well if your plane is about to crash

icic.org

Essential Element of Good Chronic Illness Care

Informed,ActivatedPatient

ProductiveInteractions

PreparedPractice Team

icic.org

What characterizes a “prepared” practice team?


At the time of the visit, they have the patient information, decision support, people,

equipment, and time required to deliver evidence-based clinical management and

self-management support

icic.org

What characterizes a “informed, activated” patient?

Patient understands the disease process, and realizes his/her role as the daily self manager. Family and caregivers are engaged in the patient’s

self-management. The provider is viewed as a guide on the side, not the sage on the stage!


icic.org

Assessment of self-management skills and confidence as well as clinical statusTailoring of clinical management by stepped protocolCollaborative goal-setting and problem-solving resulting in a shared care planActive, sustained follow-up




How would I recognize aproductive interaction?

icic.org



Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Improved Outcomesicic.org

Self-management Support

• Emphasize the patient's central role.• Use effective self-management support

strategies that include assessment, goal-setting, action planning, problem-solving and follow-up.

• Organize resources to provide support

icic.org

Delivery System Design

• Define roles and distribute tasks amongst team members.

• Use planned interactions to support evidence-based care.

• Provide clinical case management services.• Ensure regular follow-up.• Give care that patients understand and that fits their

culture

icic.org

Features of case management

• Regularly assess disease control, adherence, and self-management status

• Either adjust treatment or communicate need to primary care immediately

• Provide self-management support• Provide more intense follow-up • Provide navigation through the health care process

icic.org

Decision Support

• Embed evidence-based guidelines into daily clinical practice.

• Integrate specialist expertise and primary care.• Use proven provider education methods.• Share guidelines and information with patients.

icic.org

Clinical Information System

• Provide reminders for providers and patients. • Identify relevant patient subpopulations for

proactive care.• Facilitate individual patient care planning.• Share information with providers and patients.• Monitor performance of team and system.

icic.org

Health Care Organization

• Visibly support improvement at all levels, starting with senior leaders.

• Promote effective improvement strategies aimed at comprehensive system change.

• Encourage open and systematic handling of problems.• Provide incentives based on quality of care.• Develop agreements for care coordination.

icic.org

Community Resources and Policies

• Encourage patients to participate in effective programs.• Form partnerships with community organizations to

support or develop programs.• Advocate for policies to improve care.

icic.org

Let’s Look at Examples

• Diabetes (Kirkman will discuss)• Heart Failure• Depression• Hypertension• Prevention• Arthritis (Hawker and Allen will discuss)




Functional and Clinical Outcomes:Reduced Hospitalizations

Improved health-related quality of life

DeliverySystemDesign:

PCP, pharmacist, educator work

together to manage patient in

office and on phone

Decision Support:

Guidelines embedded

in care system (visit

planner)

ClinicalInformation

SystemsRegistry to track

patients and ensure receiving

core quality

Self-Management

Support:Literacy appropriate

educational materials, reminder

calls/education, clearly distilled plans

Health System:4 Academic Health CentersCommunity

Heart Failure Management

DeWalt et al. Circulation. 2012 Jun 12;125(23):2854-62.DeWalt et al. BMC Health Serv Res. 2006 13;6:30. McAlister et al. J Am Coll Cardiol. 2004 18;44(4):810-9.




Functional and Clinical Outcomes:Incr. Use of antidepressants

Incr. Use of counseling80% remission in 2 yrs (40% for usual care)

Higher role functioning


PCP, nurse and office staff all

involved.Monthly contact

with pts by phone via nurse

Decision Support:AHCPR

guidelinesPsychia-

trist review and advice

on tx adjust

ClinicalInformation

SystemsPt roster with tx

summaries, feedback to care

team

Self-Management

Support:office nurse provided

info on treatment options, readiness

intervention, tx effectiveness assessment

Health System:12 PCPs in US metro and non-metro)Community

Depression

Rost et al BMJ 2002;325:934

icic.org




Functional and Clinical Outcomes:Better Blood Pressure Control


Pharmacist working together

with PCP,Remote visits with home BP.

Decision Support:

Medication algorithms, refill data, reminders

ClinicalInformation

SystemsIntegrate

multiple BP readings, recall if not in control

Self-Management

Support:Affordable medicine

Physical activityNutrition

Goal settingHome BP monitor

Health System:

Community

Hypertension

Bosworth et al. Ann Intern Med. 2009 Nov 17;151(10):687-95Bosworth et al. Am Heart J. 2009 Mar;157(3):450-6.




Functional and Clinical Outcomes:Better functional status, better nutrition, higher screening rates,


Easy scheduling, pre-visit decision

aids, health educator, access

to facilities (gym)

Decision Support:

Reminders to clinical team, information for patients

ClinicalInformation

SystemsRegistry to

monitor appropriate

screening and counseling

Self-Management

Support:Physical activity

NutritionGoal setting

Navigation for screening

Health System: Commitment to prevention

CommunityAccess to walking,

healthy foods, mindfulness, social

capital

Prevention

Multiple Chronic Illnesses is the Rule, not the Exception

Planning Productive Interactions for Chronic Conditions

Additional Diagnoses* 45%

Functional Limits** 50%

> 2 Symptoms*** 35%

Not Good Health Habits 30%

*Arthritis (34%), obesity (28%), hypertension (23%),cardiovascular (20%), lung 17%)** Physical (31%), pain (28%), emotional (16%), daily activities (16%)*** Eating/weight (39%), joint pain (32%), sleep (25%), dizzy/fatigue(23%), foot (21%), backache (20%)

For Example: Diabetic Needs

icic.org

Number of Chronic Conditions per Medicare Beneficiary

Number of Conditions

Percent of Beneficiaries

Percent of Expenditures

0 18 1

1 19 4

2 21 11

3 18 18

4 12 21

5 7 18

6 3 13

7+ 2 14

63% 95%

icic.org

Guidelines are Essential, but not Sufficient

Recipe for Improving Outcomes

Evidence-basedClinical ChangeConcepts

Learning Model

System ChangeConcepts

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

System change strategy

icic.org

Drivers for Changing Models of Care

• Accountable leadership• Partnerships that promote quality of care• Attractive motivators and incentives• Transparent performance measurement• Organized quality improvement effort• Consumer engagement• Plans for sustainability

Margolis et al. J Contin Educ Health Prof. 2010;30(3):187-96.

How are these levers getting pulled?

• Motivators and incentives– pay for performance– Payment for Patient Centered Medical Home

• Transparent performance reporting– NCQA– Public reporting in some markets

• Organized Quality Improvement– Collaboratives and practice facilitation increasingly available

• Consumer engagement– Patients like me– Patient associations (Crohn’s and Colitis Foundation)

Summary

• CCM identifies the key aspects of care for the future

• Successful implementation of CCM improves outcomes across a variety of conditions/prevention

• Changing the system of care is required to successfully implement the CCM

• Several levers can influence the pace and success of large-scale system transformation

organizing care for patients with chronic diseases darren a. dewalt, md, mph associate professor...

Documents