The Chronic Care Model : A Framework for Improving Care for Your Patients

1. The Chronic Care Model:A Framework for Improving Care for Your Patients Lisa M. Letourneau MD, MPH MaineHealth 2006

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 care

3. Current “Systems”

6. Why Change? Meet Ms. D. • 46 yr old mother, wife, & bookkeeper • Seen by PCP 4X/ in past 6mos - multiple c/o’s • Sx: fatigue, non-specific sx • PE: Wgt 180, BP 145/92, no other abnl findings • Initial dx stress, ?depression

7. The Story of Ms. D… • On 3rd visit, fasting blood sugar 145:”borderline” diabetes • Advised to “watch diet, lose weight” • 1 yr later: Wgt 182, 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

8. Ms. D: Atypical, or too-familiar? “Usual” chronic illness care… • Oriented to acute illness • Focus on symptoms, tests, lab results • Focus on physician’s treatment, not patient’s role in management • Interaction frustrating for both patient and doctor • Incentives favor “expeditious resolution”, not targeted outcomes

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

10. Time for a Different Approach? • Emphasis for change to date has been on physician, not system • Characteristics of successful, evidence-based interventions weren’t being categorized usefully • Common interventions that improve outcomes across chronic conditions not fully appreciated

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

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

13. Self-Management Support • Support patient’s ability to manage their own condition • Identify what’s important to your patient • Use effective behavior change methods • Make the patient a partner in care – can require a culture shift!

14. Supporting Self-Management What are the barriers? • Lack of standard messages, education materials • Limited time • Many providers not well trained in science of behavior change • Lack of, unfamiliarity with self-care tools • Other…

15. Self-management Support • Use standard, basic patient education materials to give repeated, consistent messages • Use self-care tools (e.g. self-care card, goal-setting sheets), assess confidence, identify barriers for making change • Encourage referrals for formal self-management education and training (e.g. diabetes self-management training, asthma education, cardiac rehab)

16. 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-compliant patient”

17. Changing Your Role… “Education is not the filling of a pail, but the lighting of a fire” William Butler Yeats

18. How important is the change to the patient? How confident are they that they can make the change? Collaborative Goal-Setting Tools 1 2 3 4 5 6 7 8 9 10 • What barriers are likely to get in the way?

21. Create a supportive practice team Doc can’t do it alone – need everyone to work up to their full capacity Everyone has a role – identify and train staff to maximize their role Delivery System Design

22. Barriers to Using a Team Approach? • Culture shift! (for some…) • Roles for team members not clearly defined • Training needs? • Communication channels

23. What Characterizes a “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

24. Redesigning the Care Team • Use “planned care” visits (can’t rely on just acute care visits) • - Prepare patient for visit (bring meds, take off shoes) • - Use visit templates, flow sheets, standing orders • Provide follow-up care according to guideline recommendations • Consider alternative care models – e.g. group visits, follow-up phone calls

25. Using a Team Approach

26. Can’t rely on memory alone! (think of flying…) Get tools into practice to help providers make the right decision – every time! Translate guidelines into practice! Clinical Decision Support

27. Barriers to Evidence-based Clinical Decision Making? • Lack of objective assessments (e.g. BMI, depression score) • Fear of naming the problem (e.g. diabetes, asthma) • Often difficult to translate guidelines to care algorithms • Clinical inertia – reluctance to treat to evidence-based goals

28. Clinical Decision Support • Embed guidelines into practice by using practical tools, algorithms – e.g. - Diabetes flow sheet; BP/glycemic control algorithms • Encourage case-based learning, alternative models for provider education • Integrate specialist expertise when needed

30. Use data to track care & outcomes – any system can work! Can’t measure what you can’t improve Use your data to improve the health of individuals and populations – don’t need to wait for EMR! Clinical Information Systems

31. Barriers to Using Information Systems?? • What information systems? • Unfamiliar approach • Time, time, time!

32. Clinical Information Systems • Any system will do • EMR – IF have way to look at outcomes • Electronic registry • Paper systems • Use clinical information systems (registry) to… • Summarize key issues at point of care • Create provider, practice reports to periodically 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

35. The “Five Stages of Data” • Denial (“Those aren’t MY numbers”) • Anger / resentment (“Who got those numbers?”) • Bargaining (“How about if we re-run it again??…”) • Depression (?!!) ( “Why are we even doing this?…”) • Acceptance ( “How can we get better?”) (“Stages of Grief”–E. Kubler-Ross – adapted by M. Albaum MD)

36. Recognize practice as situated within larger community – do you know your community? Form partnerships with local community resources Strengthen connections with local Healthy Maine Partnerships Raise public awareness through community education Community Resources

37. Barriers to Connecting with Communities? • What community resources? • Connections not made • Unfamiliar roles • Communication channels not established • Time, time, time…

38. 31 Healthy Maine PartnershipService Areas

40. But Does It Work???

41. 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 • Pt attends ADEF, self-management goals set; starts local walking program • Nurse calls Ms. D. 2 wks later – answers questions about med side effects, encourages f/u visit

42. Ms. D. – A Better Ending… • PCP f/u visit at 1 mo: Starts oral meds (covered by hlth plan) • 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. How do Practices Make the Care Model “Real”? • Support patients to understand, manage their own condition(s) • Build on evidence-based guidelines • Use the tools! • Lots of locally-developed patient & provider tools! • Get support for change: MH Learning Community! • Educational sessions - Learn from peers • Tools - Coaching • Use “rapid cycle” framework for change (PDSA!)

44. Getting Started • What about this is exciting? • What about this is terrifying? • What do you need to be successful? • Let’s spend the rest of the day sharing practical ideas that will make this all possible.

45. It’s Time to Start… • Start where you are. • Use what you have. • Do what you can. ~ Arthur Ashe ~

47. 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