the chronic care model presenter improving chronic illness care, a national program of the robert...

The Chronic Care Model

Presenter

Improving Chronic Illness Care,a national program of the Robert Wood Johnson Foundation

Living with chronic illness is like piloting a small plane

To get safely to their destinationpilots need:

• Self-Management Support

• Effective ClinicalManagement

• Treatment Plan

• Close Follow-up

• Flight instruction

• Preventive Maintenance

• Safe Flight Plan

• Air Traffic ControlSurveillance

Usual care works well if your plane is about to crash

Three Biggest Worries About Having A Chronic Illness (Age 50 +)

1. Losing Independence

2. Being a Burden to Family or Friends

3. Not Being Able to Afford Needed Medical Care

Percent Somewhat or Strongly Disagreeing With Statements

Age 50-64 Age 65+

Government programs are adequate to meet the needs of people with chronic medical conditions

Health insurance pays for most of services chronically ill people need

People with chronic medical conditions receive adequate medical care

65%

55%

66%

47%

43%

52%

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%63% 95%95%

Prevalence of chronic conditions

• 10.3 % have heart disease

• 23% have HTN

• 9.1% have asthma

• 6.2% have diabetes

• Prevalence of HTN and diabetes increased in Hispanics and blacks

The IOM Quality report: A New Health System for the 21st Century

http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument

The IOM Quality Report:Selected Quotes

• “The current care systems cannot do the job.”

• “Trying harder will not work.”

• “Changing care systems will.”

IOM Report: Six Aims for Improving Health Systems

• Safe - avoids injuries

• Effective - relies on scientific knowledge

• Patient-centered - responsive to patient needs, values and preferences

• Timely - avoids delays

• Efficient - avoids waste

• Equitable - quality unrelated topersonal characteristics

Recent literature on care

• Insert here

• Recently published literature that demonstrates the gap between what we know and what we do.

•

Diabetes

• 69% had HbA1c test in last year

• 63% had feet checked

• 64% had dilated eye exam

• Among uninsured, only 62% had HbA1c, 48 % a foot exam, 49% an eye exam)

Asthma

• 48% take prescribed medications

• 29% report using steroid inhalers

• 17% report having a peak flow meter at home

Use of statins in pts with MI

• 60% of patients over age 65 with a history of a heart attack were on a cholesterol-lowering medication

• 33% knew the result of their most recent cholesterol measurement

Ayanian et al Arch Inter Med 2002;162:1013

Hypertension care in US

• Over 16,000 patients

• 27% had hypertension

• 15-24% had controlled hypertension

• 27-41% unaware that they had hypertension

• 25-32% had treated uncontrolled hypertension

• 17-19% aware of hypertension but it was untreated

NEJM 2001;345:479-486

Physician treatment practices for hypertension

• 41% had not heard of JNC guidelines

• JNC guidelines recommend treatment to 140/90

• 43% of MDs would not start therapy unless systolic >160 and 33% would not start treatment unless diastolic >95

• Most would choose ACE for first drug

Hyman et al Arch Inter Med 2000;160:2281

Children with asthma

• Affects 75 children per 1,000

• Disproportionately affects children of low income families, males and blacks over whites

• 24% of children with asthma miss two or more weeks of school (8% of children without asthma have the same attendance figures.)

• The healthcare expenditures for a child with asthma are 2.5 times that of a child without asthma.

Diabetes Care in the U.S.Harris. Diab Care 2000;23:754-8

0%

20%

40%

60%

80%

100%

HbA1c<8

BP<140/90

LDL<130

ASA Use

Eye Exam

Flu Shot

Systems are perfectly designed to get the results they achieve

The Watchword

Improving Chronic Illness CareA national program of the Robert Wood Johnson Foundation

Mission

to improve the health of chronically ill patients

by helping health plans and provider groups,

especially those that serve low income

populations, improve their care of the

chronically ill.

Evidence-basedClinical ChangeConcepts

A Recipe for Improving Outcomes

LearningModel

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

Select Topic

Planning Group

Identify Change

Concepts

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Action Period Supports

E-mail Visits Web-site

Phone Assessments

Senior Leader Reports

Event

A D

P

S

(12 months time frame)

System Change ConceptsWhy a Chronic Care Model?

• Emphasis on physician, not system, behavior

• Characteristics of successful interventions weren’t being categorized usefully

• Commonalities across chronic conditions unappreciated.

Model Development 1993 --• Initial experience at GHC

• Literature review

• RWJF Chronic Illness Meeting -- Seattle

• Review and revision by advisory committee of 40 members (32 active participants)

• Interviews with 72 nominated “best practices”, site visits to selected group

• Model applied with diabetes, depression, asthma, CHF, CVD, arthritis, and geriatrics

Essential Element of Good Chronic Illness Care

Informed,ActivatedPatient

ProductiveInteractions

PreparedPractice Team

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

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!


•Assessment of self-management skills and confidence as well as clinical status•Tailoring of clinical management by stepped protocol•Collaborative goal-setting and problem-solving resulting in a shared care plan•Active, sustained follow-up




How would I recognize aproductive interaction?



Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Improved Outcomes

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

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

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

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.

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.

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.

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.

To Change Outcomes (e.g., HbA1c) Requires Fundamental Practice Change

• Interventions focused on guidelines, feedback, and role changes can improve processes

• Interventions that address more than one area have more impact

• Interventions that are patient-centered change outcomes.

Renders et al, Diabetes Care, 2001;24:1821

Impact of disease management on control (number of positive trials)

• Provider education = 12/32

• Provider feedback = 9/23

• Provider reminders = 6/14

• Patient education = 24/55

• Patient reminders = 6/16

• Patient financial incentives =3/4

Weingarten et al BMJ 2002;325:925

Features of case management

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

• Either adjusts treatment or communicates need to primary care immediately

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

process

Impact of Planned Care and Collaborative Goal-Setting

• Randomized Danish GPs to diabetes intervention groups

• Intervention group trained to provide regular goal-setting in periodic structured visits with their diabetic patients

• Study team provided guidelines, training, reminders, and regular feedback

• Mean HbA1c significantly better years later

Olivarius et al. BMJ 10/01

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

Advantages of a General System Change Model

• Applicable to most preventive and chronic care issues

• Once system changes in place, accommodating new guideline or innovation much easier

• Early participants in our collaboratives using it comprehensively

The Growing Burden of Non-communicable Disease

• Rapidly aging population

• Increased environmental risks—smoking, changed diet, increasing inactivity, air pollution

• Double jeopardy: still fighting infectious disease and malnutrition while experiencing impacts of chronic disease

W.H.O. Innovative Care for Chronic Conditions, 2002W.H.O. Innovative Care for Chronic Conditions, 2002

Conmmunity is Critical Source of Care and SupportConmmunity is Critical Source of Care and Support

Applying the CCM to prevention

Similarities:

• Require regular attention to behavior change

• Are population-based

• Require planned care and active follow-up

• Use decision guides and occur in primary care

• Require patient involvement

• Require provider training

• Community linkages are helpful

Applying the CCM to prevention

Differences:

• Prevention visits are less frequent

• Changing behaviors to prevent something may be different than when have an illness

• Prevention may not be as well reimbursed

• Benefits of prevention more difficult to perceive

• Few people specialize in prevention

Glasgow et al Milbank Quarterly 2001;79:579

•www.improvingchroniccare.org

Contact us:

thanks




Functional and Clinical Outcomes:Reduce readmission rate

Non-significantly lower mortalityIncreased quality of life

DeliverySystemDesign:

Nurse case manager

Hospital and home visits

Telephone F/U

Decision Support:

Guidelines Ongoing

consultation with

cardiologist

ClinicalInformation

Systems

Self-Management

Support:Standardized educational

program

Health System:Barnes-Jewish Hospital St. LouisCommunity

Congestive Heart Failure -- Rich et al

Rich et al, NEJM 1995




Functional and Clinical Outcomes:Decreased emergency room use, repeat admits, specialist use

Increased calls to nurses, decreased calls to doctorsIncreased immunizations

Increased satisfaction for patient and provider


Multidisciplinary Group Visits

Decision Support:Provider

Education, Clinical

Priorities

ClinicalInformation

SystemsPatient

Notebook

Self-Management

Support:Group

EducationPeer Interaction

Health System:Kaiser-Permanente ColoradoCommunity

Cooperative Health Care Clinic

Beck et al, JAGS 1997;45:543



Prepared,ProactiveGNP reporting to PCP

Functional and Clinical Outcomes:Decreased disability and increased activity levels

Decreased hospitalizationIncreased socialization

Decreased psychoactive medication use


GNP visits, peer mentors

Decision Support:

Evidence-based

Protocols

ClinicalInformation

Systems:Electronic Chart and Follow-up

System

Self-Management

Support:Individual and

Group Interactions

Health System:GHC and PacifiCareCommunity:

Northshore Senior

Center

Health Enhancement Project

Leveille et al, JAGS 1998;46:1191




Functional and Clinical Outcomes:Increased retinal, foot and renal screening rates,

Increased Hemoglobin A1c testing,Increased proactive/planned care,

Reduced costs,Increased satisfaction for patient and provider


Multidisciplinary Group Visits,Planned visits,

Retinal Screening Program

Decision Support:

Guidelines,Expert Team,

Provider Education

ClinicalInformation

SystemsOn-line Registry,

Practice Reports,

Reminders,Patient

Summaries

Self-Management

Support:Right Track

Notebook/Phone Program,

Lorig Support Groups

Health System:Group Health Cooperative of Puget SoundCommunity

The Diabetes Clinical Improvement Roadmap

McCulloch et al Eff. Clin Prac 1998;1:12,

Dis Mgmt 200;3:75




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

Ongoing Depression Treatment

Rost et al BMJ 2002;325:934




Functional and Clinical Outcomes:decreased HbA1c

no increase in adverse eventsimproved self-reported health status


case mgmt.RN in clinic,

routine meetingswith PCP

Decision Support:Detailedmanage-

mentalgorithms,specialistconsult.

ClinicalInformation

Systemsdiabetes registry,

patient monitoring logs

Self-Management

Support:1:1 visits withtrained RN,

follow-upsupport,

pt. Ed class

Health System:Prudential JacksonvilleCommunity

Diabetes Nurse Case Management

Aubert et al Ann Int Med 1998;129:605

Patient/Caregiver Problem-Centered

Interactions

Case managerlinked to others

Increased hospitalizationNo change in functional status


intensivecase mgmt(home visit

every 6 wks, monthly

phone calls)

Decision Support

no clinical guidelines

consult withgeriatrician

and team

ClinicalInformation

Systemsused a nursing documentation

program

Self-Management

Supporttrained to

emphasize patientstrengths

Health System

Resources and Policiesdeveloped a guidereferred patients

Community Health Care OrganizationRegional health system

Non-specific Nurse Case Management

Gagnon et al, JAGS 1999; 47:1118-1124

UnmotivatedPatient/Family Ineffective

Interactions

Practice Nurse working in isolation

No improvement in QOL, ER useor anti-inflammatory use


Asthma nurseworking withpractice nurse

who runs asthma clinic

Decision SupportThoracic Society

Guidelines.Six teachingsessions with

nurses

ClinicalInformation

SystemsNot described

Self-Management

SupportStandardized information

Health System

Resources and PoliciesNo links to ER or hosp.Asthma Resource Centerin hospital

Community Health Care OrganizationRegionalized health system (UK)

Asthma Resource Center

Premaratne et al BMJ 1999;318:1251-1255

Stages of Coping with Data

• Stage 1: The data are wrong.

• Stage 2: The data are right, but it’s not a problem.

• Stage 3: The data are right, it’s a problem, but it’s not my problem.

• Stage 4: The data are right, it’s a problem, and it’s my problem.

"Ultimately, the secret of quality is love. You have to love your patients, you have to love your profession, you have to love your God. If you have love, you can work backward to monitor and improve the system."

Donabedian

the chronic care model presenter improving chronic illness care, a national program of the robert...

Documents

medical care slide

strategy slide

home slide

watchword slide

practice team slide

eye exam slide

hypertension care

small plane slide