Presentation Title

1. Presentation Title MaineHealth Diabetes, Obesity, Cardiovascular “DOC” Collaborative The Chronic Care Model: A Framework to Improve Diabetes Care Lisa Letourneau MD, MPH

2. Objectives • Describe model for improving chronic illness care and prevention that is… • Patient-centered • Interdisciplinary • Evidence-based • Demonstrate how Chronic Care Model can provide an effective framework for practices to improve diabetes care

3. Why Change? Meet Ms. D. • 56 yr old mother, wife, & bookkeeper • Seen by PCP 4X/ in past 6mos - multiple complaints • Sx: fatigue, non-specific sx • PE: Wgt 180, BP 145/92, no other abnl findings • Initial dx stress, ?depression

4. The Story of Ms. D… • On 3rd visit, fasting blood sugar 145: told “borderline” diabetes • Advised to “watch diet, lose weight” • Follow up suggested in one year

5. The Story of Ms. D… • 1 yr later: Wgt 187, BP 150/90; Fasting blood sugar 165 • PCP prescribes metformin • Doesn’t pick up meds (too expensive) • 6 mos later: seen by coverage for blurred vision, headaches • Unable to work for past X2 wks • Blood sugar 450…

6. Atypical or Too-familiar Story? “Usual” chronic illness care… • Oriented to acute illness • Focus on symptoms, tests, lab results • Geared towards physician’s treatment, not patient’s role in management • Interaction frustrating for patient, doctor • Incentives favor “expeditious resolution”, not targeted outcomes

7. Current “Systems”

8. “Systems are perfectly designed to get the results they achieve”-Paul Batalden The Watchword

9. The Results We are Achieving… • Saddine 2002: charts of 4000+ patients • 18% poor HbA1c control (>9.5) • 34% BP >140/90 • 68% LDL >130 • 37% no evidence dilated eye exam in prior yr • 45% no evidence of foot exam in prior year Saaddine et al., Ann Int Med Apr 2002

10. Why the Gaps? • “Tyranny of the urgent”! • Increased demands for time, attention in PCP setting • Current system does not support, reward better population-based outcomes • Need a different system of care!

11. Essential Elements of Good Chronic Illness Care Informed, Activated Patient Prepared Practice Team Productive Interactions Improved Outcomes

12. What Characterizes an “Informed, Activated” Patient? Informed, Activated Patient • Patient… • understands the disease process • realizes his/her role as the daily self manager • Family and caregiver… • are engaged in patient’s self-management • The provider is viewed .. • as a guide on the side, not “the sage on the stage”!

13. What Characterizes a “Prepared” Practice Team? Prepared Practice Team • At the time of the visit, the care team has… • patient information • decision support • people, equipment, and time • … required to deliver evidence-based clinical management and self-management support

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

15. The Chronic Care Model in Action MaineHealth TARGET Diabetes Program

16. Chronic Care Model for Diabetes Health System Community Resources and Policies Health Care Organization Patient & Family Education & Self-Management Support DeliverySystem Design ClinicalInformationSystems Decision Support • Support patient’s ability to understand, manage their diabetes • Use standard, basic patient education materials (consistent messages) • Encourage referrals for formal diabetes education • Promote use of diabetes self-care tools (TARGET self-care report, goal setting tools) • Practice collaborative goal setting, problem-solving (vs.seeking “compliance”)

17. Self-management Support • Use standardized patient ed materials, tools – e.g TARGET self-care cards, educational booklets • Focus on collaborative self-management goals

18. Think differently! Focus on collaborative goal setting with patients Effectively support behavior change with patients: Do you want to make a change? How are you going to make the change? What can I do to help you? Moving beyond “compliance”… “Non-compliance”

19. The informed patient is part of the “team” in this new model of “delivery system redesign”

20. Chronic Care Model for Diabetes Health System Community Resources and Policies Health Care Organization Decision Support ClinicalInformationSystems Education & Self-Management Support DeliverySystem Design • Know who’s on your team! • Identify, build care team (including local diabetes educator) – need to identify, value explicit roles for all team members • Use planned diabetes visits (can’t rely solely on acute care visits) • Provide follow-up care according to guideline recommendations • Consider alternative care models – e.g. group visits, follow-up phone calls

21. Delivery system redesign: Every member of the team has a role!

23. Chronic Care Model for Diabetes Health System Community Resources and Policies Health Care Organization DeliverySystem Design ClinicalInformationSystems Decision Support Education & Self-Management Support • Translate guidelines into practice! • Use evidence-based guidelines (ADA Standards) to drive care • Embed guidelines in practical tools, algorithms – e.g. • - Diabetes flow sheet; BP/glycemic control algorithms • Encourage case-based learning, alternative models for provider education • Access, integrate specialist expertise when needed

24. Decision Support Tools: Algorithms, guidelines, and flowsheets promote consistency of care

28. Chronic Care Model for Diabetes Health System Community Resources and Policies Health Care Organization ClinicalInformationSystems DeliverySystem Design Decision Support Education & Self-Management Support • Use data to improve health of individuals and populations! • Use diabetes registry to identify patient populations, track key diabetes, CVD outcomes • Use registry progress reports to monitor performance, provide data feedback • Identify high-risk pt subgroups needing proactive care – e.g. • - HbA1C>9%; pt’s without visit in past 12 mos; needing labs

29. Using registry as a tool to support proactive care

32. TARGET Diabetes Self-Care Action Plan

34. Chronic Care Model for Diabetes Community Resources and Policies Health System Health Care Organization Education & Self-Management Support DeliverySystem Design ClinicalInformationSystems Decision Support • Develop partnerships with Maine Diabetes Prevention & Control Program, local DSME programs, ADA, • Become aware of, link with community educational resources • Strengthen connections with local Healthy Maine Partnerships • Partner with workplaces, schools, faith communities • Raise public awareness through community education, PSA’s Adapted from Homer C., National Initiative for Children’s Health Care Quality

36. But Does It Work???

37. Diabetes Collaboratives 1 & 2 Ask them!!

38. Advantages of General System Change Model • Applicable to most chronic care issues • Once system changes in place, accommodating new guideline or innovation much easier • Focus is on improving system, not finding fault with individuals • Can be readily adapted for improving preventive care

39. Ms. D. Revisited • Hears local “pre-diabetes” PSA • Takes ADA “Risk Test”; books PCP visit; FBS ordered pre-visit • PCP dx’s Type 2 diabetes, offers “TARGET Diabetes Info” booklet, sched’s follow up visit in 2 wks • Follow up visit: HbA1c 8.8%; results recorded w/ pt; referred for diabetes education

40. Ms. D revisited… • Pt attends ADEF classes, sets self-management goal • Starts local walking program, takes grocery store tour • PCP f/u visit at 1 mo: Starts oral meds (covered by health plan) • Nurse calls Ms. D. 2 wks later – answers questions about med side effects, encourages f/u visit

41. Ms. D. – A Better Ending… • Ms. B able to continue working; husband, kids notice significant improvements • HA’s, fatigue diminishing • Follow up PCP visit at 8 wks: sx much improved, HbA1c 8.1% • Plan to continue meds, taper care manager calls, f/u in 2 mos

43. For more info: • Chronic Care Model references • www.improvingchroniccare.org • www.mainehealth.org Adapted from presentation by Ed Wagner M.D, MPH, Macoll Institute, Group Health Puget Sound