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Learn about the care model for living with chronic illnesses, emphasizing patient-centered care, preventive measures, and effective clinical management. Discover the key elements for better outcomes and improved quality of life. -
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The Care Model Connie Davis, MN, ARNP Assoc. Director for Clinical Improvement, Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation MacColl Institute Center for Health Studies Group Health Cooperative Seattle, WA
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
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
Number of Chronic Conditions per Medicare Beneficiary 95% 63%
Prevalence of chronic conditions • 10.3 % have heart disease • 23% have high blood pressure • 6.2% have diabetes • 5% have depression • 3% have or had a diagnosis of cancer
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 • Vitality (not from IOM)
Gaps in Care • 25% of patients with diabetes have heart disease risk addressed • 27% of patients with hypertension are adequately treated • 45% have had colon cancer screening • 25% of people with depression are receiving adequate treatment
Why the gap? • Irresponsible patients? • Uninformed professionals? • A broken health care system?
Systems are perfectly designed to get the results they achieve The Watchword
Improving Chronic Illness CareA national program of the Robert Wood Johnson Foundation
Evidence-based Clinical Change Concepts System Change Concepts A Recipe for Improving Outcomes System change strategy Learning Model
System Change ConceptsWhy a Chronic Care Model? • In the past, 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, prevention and geriatrics • Model supported by structured reviews (Renders, 2001; Weingarten, 2002; Bodenheimer, 2002; Norris, 2001) • Model now enhanced for all aspects of outpatient care (AHRQ, IHI) and developing nations (WHO)
Essential Element of Good Chronic Illness Care Prepared Practice Team Informed, Activated Patient Productive Interactions
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
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!
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
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
Self-management Support • Emphasize the patient's central role. • Use effective self-management support strategies (5 A’s). • 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 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
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.
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.
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.
Cochrane Review of Interventions to Improve Diabetes Care in Primary Care • 41 studies, majority randomized trials • Interventions classified as provider-oriented, organizational, information systems, or patient-oriented • Patient outcomes (e.g., HbA1c, BP, LDL) only improved if patient-oriented interventions included • All 5 studies with interventions in all four domains had positive impacts on patients Renders et al, Diabetes Care, 2001;24:1821
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
Advantages of a General System Change Model • Applicable to 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, 2002
"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
Contact us: www.improvingchroniccare.org thanks