The Chronic Care Model

1. The Chronic Care Model Presenter Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation

2. Living with chronic illness is like piloting a small plane

3. To get safely to their destinationpilots need: Flight instruction Preventive Maintenance Safe Flight Plan Air Traffic ControlSurveillance Self-Management Support Effective ClinicalManagement Treatment Plan Close Follow-up

4. Usual care works well if your plane is about to crash

5. Three Biggest Worries About Having A Chronic Illness (Age 50 +) • Losing Independence • Being a Burden to Family or Friends • Not Being Able to Afford Needed Medical Care

6. Percent Somewhat or Strongly Disagreeing With Statements Age 50-64Age 65+

7. Number of Chronic Conditions per Medicare Beneficiary 95% 63%

8. 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

9. The IOM Quality report: A New Health System for the 21st Century http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument

10. The IOM Quality Report:Selected Quotes • “The current care systems cannot do the job.” • “Trying harder will not work.” • “Changing care systems will.”

11. 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

12. Recent literature on care • Insert here • Recently published literature that demonstrates the gap between what we know and what we do.

13. 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)

14. Asthma • 48% take prescribed medications • 29% report using steroid inhalers • 17% report having a peak flow meter at home

15. 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

16. 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

17. 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

18. 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.

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

20. Systems are perfectly designed to get the results they achieve The Watchword

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

22. Evidence-based Clinical Change Concepts System Change Concepts A Recipe for Improving Outcomes System change strategy Learning Model

23. 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.

24. 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

25. Essential Element of Good Chronic Illness Care Prepared Practice Team Informed, Activated Patient Productive Interactions

26. What characterizes a “prepared” practice team? 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

27. What characterizes a “informed, activated” patient? 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!

28. How would I recognize a productive interaction? Prepared Practice Team Informed, Activated Patient Productive Interactions 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

29. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

30. 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

31. 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

32. 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

33. 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.

34. ClinicalInformation System • Provide reminders for providers and patients. • Identify relevant patient subpopulations for proactive care. • Facilitateindividual patient care planning. • Share information with providers and patients. • Monitor performance of team and system.

35. 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.

36. 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.

37. 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

38. 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 Impact of disease management on control (number of positive trials) Weingarten et al BMJ 2002;325:925

39. 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

40. 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

41. Planning Productive Interactions for Chronic Conditions For Example: Diabetic Needs *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%)

42. 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

43. 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, 2002

44. Conmmunity is Critical Source of Care and Support

46. 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

47. 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

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49. Congestive Heart Failure -- Rich et al Health System:Barnes-Jewish Hospital St. Louis Community Self-Management Support:Standardized educational program ClinicalInformationSystems DeliverySystem Design: Nurse case manager Hospital and home visits Telephone F/U Decision Support:Guidelines Ongoing consultation with cardiologist Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes: Reduce readmission rate Non-significantly lower mortality Increased quality of life Rich et al, NEJM 1995

50. Cooperative Health Care Clinic Health System:Kaiser-Permanente Colorado Community Self-Management Support:Group EducationPeer Interaction ClinicalInformationSystems Patient Notebook DeliverySystem Design: Multidisciplinary Group Visits Decision Support:Provider Education, Clinical Priorities Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes: Decreased emergency room use, repeat admits, specialist useIncreased calls to nurses, decreased calls to doctorsIncreased immunizationsIncreased satisfaction for patient and provider Beck et al, JAGS 1997;45:543