Redesigning Care to Meet the Needs of the Chronically Ill Patient

1. Redesigning Care to Meet the Needs of the Chronically Ill Patient Mike Hindmarsh Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation

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

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

4. 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

5. 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!

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. Early research findings about The Care Model

16. RAND Evaluation questions • Do organizations in a Collaborative change their systems for delivering chronic illness care? • Does implementing the Chronic Care Model improve processes of care and patient health • http://www.rand.org/health/ICICE

17. RAND Findings Comparing Collaborative Participant Patients with Controls • Decreases in HbA1c for patients with diabetes • Significant increase in patient reports of counseling, education and improved lifestyle for CHF • Significant improvement in QOL for patients with asthma • Significant increase in patients on controller medications

18. Health system experiences

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

20. Chronic Conditions Collaboratives Mechanism for spreading health system change via the Chronic Care Model 13 month intensive improvement efforts working with multiple teams from varying health systems Over 1000 health care systems involved to date Both national and regional collaboratives Collaboratives: frailty in the elderly, diabetes, CHF, asthma, depression, arthritis, AIDS, CVD, prevention

21. Regional Collaboratives (past & present) • Washington State: Diabetes I, II, III • Alaska: Diabetes • Oregon: Diabetes, CHF • Chicago: Diabetes • Vermont: Diabetes I, II • New Mexico: Diabetes • Wisconsin: Diabetes I, II • Arkansas: Diabetes • Nevada: Diabetes

22. Regional Collaboratives (cont’d) Maine: Diabetes Rhode Island: Diabetes Arizona: Diabetes North Carolina: Diabetes New York: Asthma and Prenatal Care Indiana Chronic Disease Management Program New York Health and Hospital: Diabetes & CHF

23. Successes of Teams in Collaboratives: The Benefit of Organized Chronic Care • 1.5 - 2 times as many patients with major depression will be recovered at six months • Inner city kids with moderate to severe asthma have 13 fewer days per year with symptoms • Readmission rates of patients hospitalized with CHF will be cut nearly in half

24. Performance of 26 Delivery Systems in WA Diabetes II Collaborative

25. Premier Health Partners • Dayton, Ohio • 100 physicians in 36 practices • Change began in one practice—spread throughout system • ACE-inhibitors for albuminuria was 38% in 1999 and 80% in 2001 • A1c < 7% was 42% in 1999 and 70% in 2001

26. Disease Management Vendors • Typically single disease carve-out model • Some shift towards carve-in • Segmentation of high risk • No RCT evidence of clinical or cost effectiveness • No effort to build capacity of primary care

27. Questions to Ask DM Vendors • Carve-in or out? • How much risk? • Interventions for whole population? • Linkage to primary care providers? • Details of intervention (especially CM)? • Handling of co-morbidities?

28. What is Involved in a State Approach? Creating “systemness” on a regional level: • Strong coalition of stakeholders • IT infrastructure • Ability to reach practices through data and incentives • Clinical support via guidelines, case management, self-management support training • QI training and tools • Performance monitoring and feedback • Technical assistance for all practice types

29. www.improvingchroniccare.org Thank you