The Planned (Chronic) Care Model : A Framework for Improving Care for Your Patients

1. The Planned (Chronic) Care Model:A Framework for Improving Care for Your Patients Julie Osgood • Steve DiGiovanni, MD MaineHealth September 20, 2007

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

3. Planned Care – Key Concepts A planned care approach needs… • A care team that truly functions as a team • Patients who are informed, encouraged, and equipped to have an active role in their care • Use of care plans that are proactively designed & delivered • Clinical information system(s) that supports patient and care team • Leadership that drives & supports these elements

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

5. Current “Systems”

6. 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

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

8. Planned (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

9. The Flu Shot: It is not a lost cause • Ordering supply • Database: CIR • Multi-faceted approach • Educate families through out the year • Letters sent to families • Any visit (Acute of HCM) • Flu clinics • Phone calls to the slackers • Use the CIR to track outcomes

10. 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!

11. 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)

12. 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”

13. 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?

15. 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

17. 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

18. Redesigning the Care Team • Use “planned care” visits (can’t rely on just acute care visits) • - Prepare patient for visit (bring meds, devices) • - 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

19. Asthma Education Fax Referral • Initially needed to be provider initiated • Automatic Referral Protocol

20. 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

21. Clinical Decision Support • Embed guidelines into practice by using practical tools, algorithms - e.g. Asthma flow sheets; COPD-Asthma Algorithm • Encourage case-based learning, alternative models for provider education • Integrate specialist expertise when needed

23. Asthma • National guidelines distributed to all providers. • Classification and Medications • Referral indications • Asthma encounter sheets • Asthma action plans • ACT test for asthma

24. 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

25. 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

28. Using the Data • Need to train a leader in the office to use the data. Centralize the data.

29. 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

30. 31 Healthy Maine PartnershipService Areas

32. Utilizing a web based Clinical Improvement Registry to integrate a tobacco treatment program into pediatric asthma care.Stephen DiGiovanni, M.D., Karen L. Wathen, MPPM A collaboration between the MMC Physician-Hospital Organization (MMCPHO), the Maine Tobacco Helpline and Primary Care Providers to provide best quality tobacco treatment care to families of pediatric asthma patients. Objectives Methods • MMCPHO • Clinical Improvement Registry • Monetary Quality Awards • Educational Outreach • Maine Tobacco Helpline • Counseling • Medication • Fax Referral • Determine rates of household member tobacco use for a population of asthmatic patients aged 2 to 18. • Increase rates of provision of tobacco treatments to household members of pediatric asthmatic patients. • Implement a fax referral system to the Maine Tobacco Helpline (MTH) for household member tobacco users. Best Care • Primary Care Providers • 19 Family Practice/Pediatrics • >3,000 Pediatric Asthma Patients Outcomes 2005 2006 Pediatric asthma patients age 2-18 3,389 3,912 Households-tobacco use documented 2,496 3,047 Households positive for tobacco use 400 521 Total number of tobacco users 446 564 Quit interest documented 193 205 Interested in quitting 40 38 Quit date set/discussed 6 72 Medication discussed 45 30 Fax referred to the Maine 11 24 Tobacco Helpline Conclusions • The Clinical Improvement Registry is an efficient method to determine household member tobacco use. • Household member tobacco use was documented for 78% of asthmatic patients. • Providers did not consistently document tobacco treatments for household members. • In 2006, only 26% of smokers received a tobacco treatment. • Helpline Fax Referral is a feasible intervention tool for providers. • In 2006, 38 smokers were interested in quitting, 24 fax referrals were sent. • Methods to increase quit interest documentation needs to be developed. • If quit interest was determined, the rate of providing treatment was high.

33. THE MANTRA • Make your patient’s life better • Educate • Empower • Make your staff’s life better • Educate • Empower

34. Break it down • Patient enters the office • Patient leaves the office • Patient in the community

35. Lessons learned • Create a small leadership team • Get buy in from the entire staff • Set specific objectives • Start small but set high goals • The physician is a minor player • Change is good, be happy • Measure the program • Grow the program