The Chronic Care Model

1. The Chronic Care Model Mike Hindmarsh Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation California Chronic Care Learning Communities Initiative Collaborative Oakland, CA November 2-3, 2004 ICIC Website: http://www.improvingchroniccare.org/

2. 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

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

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

5. 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

6. 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

7. The Burden of Chronic Illness on The Acute Care System The Average Patient with Diabetes has: *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%)

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

9. 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

10. 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

11. 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

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

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

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

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

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

17. 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.

18. 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

19. 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

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

21. 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

22. 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!

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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.

29. 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.

30. 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.

31. 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.

32. 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

33. 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

34. 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

35. 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

36. 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

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

38. 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 • HbA1cs, LDLs and BPs are reduced

39. RAND Evaluation questions • Do organizations in a collaborative learning environment 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

40. 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

41. Contact us: www.improvingchroniccare.org thanks