The Chronic Care Model

1. The Chronic Care Model

2. Developed by Ed Wagner, MD, MPH and colleagues MacColl Institute for Healthcare Innovation Group Health Cooperative of Puget Sound home of the Robert Wood Johnson Foundation National Program, Improving Chronic Illness Care

3. The IOM Quality report:A New Health system for the 21st Century

4. The IOM Quality report:A New Health system for the 21st Century • “The current care systems cannot do the job.” • “Trying harder will not work.” • “Changing care systems will.”

5. improving chronic illness care Usual Chronic Illness Care • 15 minute visit, poorly organized • Symptoms and lab results focus of discussion and exam, not preventive assessment • Patient’s attempts to discuss difficulties in living with the condition are discouraged • Focus is on physician’s treatment, not patient’s role in management. • Treatment plan is limited to prescription refill and encouragement to make appointment if not feeling well • Visit ends with physician rifling through drawers looking for a pamphlet

6. improving chronic illness care Usual Care Model Health System • Health Care Organization • Leadership concerned about the bottom line • Incentives favor more frequent, shorter visits • No organized QI Community • Resources and Policies • No links with community agencies or resources Clinical Information Systems Don’t know pts or what they need Self-Management Support No systematic approach; didactic in orientation Decision Support No agreement on good care; traditional referrals Delivery System Design Reliance on short, unplanned visits Frustrating Problem-Centered Interactions Uninformed, Passive Patient Unprepared Practice Team Sub-optimal Functional and Clinical Outcomes

7. Frustrating Problem-Centered Interactions improving chronic illness care Usual Care Model Unprepared Practice Team Uninformed, Passive Patient Sub Optimal Functional and Clinical Outcomes

8. Chronic Care Model Informed, Activated Patient Supportive, Integrated Community Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes Satisfaction  Clinical Measures  Cost  External Review Measures

9. Chronic Care Model Development 1993 -- • Initial experience at GHC • Literature review • RWJF Chronic Illness Meeting -- Seattle • Review and revision by advisory committee (40 members (32 active participants) • Interviews and site visits with 72 nominated “best practices” • Model applied with diabetes, geriatrics, asthma, CHF, and depression with over 200 health care organizations

10. Themes in the Chronic Care Model • Evidence-based • Valuing excellence (and evidence) over autonomy • Patient-centered • Each patient is the only patient • Population-based

11. The Chronic Care Model Community Health System Resources and Policies Health Care Organization DeliverySystem Design Decision Support Family Education & Self- Management Support ClinicalInformationSystems Informed, Activated Patient Prepared, Proactive Practice Team Supportive, Integrated Community Productive Interactions Functional and Clinical Outcomes

12. Chronic Care Model Community Resources and Policies Health System Health System Health Care Organization ClinicalInformationSystems Family Education & Self-Management Support DeliverySystem Design Decision Support • Specific goals in organizations strategic/business plan • Senior leader support • Organization adopts performance improvement model • Provider incentives support organizational goals

13. Chronic Care Model Health System Community Health Care Organization Resources and Policies DeliverySystem Design ClinicalInformationSystems Decision Support Family Education & Self- Management Support • Evidence-based guidelines • Provider education • Referrals and specialist expertise • Guidelines for patients

14. Chronic Care Model Community Resources and Policies Health System Health Care Organization Family Education & Self-Management Support DeliverySystem Design Decision Support ClinicalInformationSystems • Emphasize patient/parent active role • Collaborative care planning/problem solving • Ongoing educational process • Connections between family/patient and social support • Standardized assessments of self-management • Written management plan with goal setting

15. Chronic Care Model Health System Community Resources and Policies Health Care Organization ClinicalInformationSystems Decision Support Family Education & Self-Management Support DeliverySystem Design • Team roles and tasks (practice team, school, parents) • Care based on accepted guidelines • Primary care team assures continuity • Regular follow-up care

16. Chronic Care Model Community Resources and Policies Health System Health Care Organization ClinicalInformationSystems Family Education & Self-Management Support DeliverySystem Design Decision Support • Registry to track clinically useful and timely information • Registry reports/data for feedback • Care reminders • Assure timely planned follow-up • Identification/proactive care of relevant patient subgroups • Individual patient care planning

17. Chronic Care Model Community Resources and Policies Health System Health Care Organization ClinicalInformationSystems Family Education & Self-Management Support DeliverySystem Design Decision Support • Partnerships • Key school contact identified • Input • Educational services available

18. How Would I Recognize Good Care for People with Chronic Illness? Informed, Activated Patient Supportive, Integrated Community Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes • Assessment and tailoring • Collaborative problem definition • Evidence-based clinical management • Goal-setting and problem-solving • Shared care plan • Active, sustained follow-up • Community integration and support