1. The Chronic Care Model Presenter Improving Chronic Illness Care,
a national program of the Robert Wood Johnson Foundation

2. Living with chronic illness is like piloting a small plane
In the four years we have been working on ICIC, we have learned from our patients.
Teresa Brady, PhD, a CDC researcher who has rheumatoid arthritis taught us to remember who is piloting the plane….try to arrange the system to support them as they pilot this small plane over the landscape of their lives.

3. To get safely to their destination pilots need:
Flight instruction
Preventive Maintenance
Safe Flight Plan
Air Traffic Control Surveillance
Self-Management Support
Effective Clinical Management
Treatment Plan
Close Follow-up
Here is a comparison of what patients need (on the left) and what that translates to in medical care (on the right.)

4. Usual care works well if your plane is about to crash
Our system has been designed for crises.

5. 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
But what are patients really concerned about?
Source: Partnership for Solutions, Medicare data and Harris polls of Medicare recipients. (from Jerry Anderson)

6. Percent Somewhat or Strongly Disagreeing With Statements
Age Age 65+
Government programs are adequate to meet the needs of people with chronic medical conditions
Health insurance pays for most of services chronically ill people need
People with chronic medical conditions receive adequate medical care
65%
55%
66%
47%
43%
52%
Our view of how well we are doing in providing good health care changes as we age and become more personally acquainted with chronic illness.
Source same as prior slide

7. Number of Chronic Conditions per Medicare Beneficiary
Number of Conditions
Percent of Beneficiaries
Percent of Expenditures 18 1 19 4 2 21 11 3 12 5 7 6 13 7+ 14
Too often we organize our care around a certain chronic condition, like diabetes, or asthma. But the data show a different story. Well over half of those over age 65 have more than one chronic condition and they account for 95% of all health care expenditures.
Source same as prior slide
63%
95%

8. 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
These data are from people age 18 and over in the US. Now that you see the prevalence, here is some quality data. Of pts with diabetes, 70% reported having a HbA1c in past year and 63% report having a foot exam. These rates are lower among the uninsured. (62% having HbA1c, 48% foot exam, 49% dilated eye exam vs. 64% in the insured population.)
Source: self-report data from 2000 Statistical Brief #5 by Marie N Stagnitti, Medical Expenditure Survey

9. The IOM Quality report: A New Health System for the 21st Century
In 2001, the Institute of Medicine published this report. What we have in the US is not a gap between what we know is good care and what we do, it is a chasm.

10. The IOM Quality Report: Selected Quotes
“The current care systems cannot do the job.”
“Trying harder will not work.”
“Changing care systems will.”
Here are some quotes from the report.
These are very applicable to Chronic Care

11. 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 to personal characteristics
Here are the aims from the report.
They kind of system change we need in chronic illness care and the care model I will describe addresses all of these aims.

12. Recent literature on care
Insert here
Recently published literature that demonstrates the gap between what we know and what we do.
Unfortunately, the literature continues to show deficits in care—the chasm
The gap between what we know and what we do.
Sources for information on chronically ill:
“A Portrait of the Chronically Ill in America” chartbook. 63 page PDF includes info on pts with 6 different conditions 16

13. Diabetes 69% had HbA1c test in last year 63% had feet checked
64% had dilated eye exam
Among uninsured, only 62% had HbA1c, 48 % a foot exam, 49% an eye exam)
Source: MEPS data from 2000, self report

14. Asthma 48% take prescribed medications
29% report using steroid inhalers
17% report having a peak flow meter at home
Sources: MEPS data, self-report over age 18

15. 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
Sources: Ayanian et al Arch Inter Med 2002;162:1013
Ayanian et al Arch Inter Med 2002;162:1013

16. 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
15% of Hispanic Americans had uncontrolled HTN, 24% in whites and blacks, more Hispanics unaware of hypertension.
Primarily isolated systolic hypertension
Uncontrolled HTN found in all groups: uninsured, insured, poor, average income
More common among those over 65
Source: Hyman et al NEJM 2001;345: , data from NHANES over age 25.
NEJM 2001;345:

17. 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
The same researcher asked 723 physicians about hypertension.
JNC=Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure.
Diuretics are generally first line drug.
These are not bad physicians. They are working in a system that doesn’t help them deliver the best care.
Hyman et al Arch Inter Med 2000;160:2281
Hyman et al Arch Inter Med 2000;160:2281

18. Children with asthma Affects 75 children per 1,000
Disproportionately affects children of low income families, males and blacks over whites
24% of children with asthma miss two or more weeks of school (8% of children without asthma have the same attendance figures.)
The healthcare expenditures for a child with asthma are 2.5 times that of a child without asthma.
Source:
Center for Healthcare Strategies Chartbook, October Based on data from

19. Diabetes Care in the U.S. Harris. Diab Care 2000;23:754-8
Data from medicare patients

20. Systems are perfectly designed to get the results they achieve
The Watchword
Systems are perfectly designed to get the results they achieve
Source, Don Berwick

21. Improving Chronic Illness Care A national program of the Robert Wood Johnson Foundation

22. A Recipe for Improving Outcomes
Evidence-based
Clinical Change
Concepts
System change strategy
System Change
Concepts
We now know it takes knowledge from a wide range of fields to improve care. We’ll be talking about three different kinds of knowledge and put them in a learning model so that we can take it all in.
The first is about clinical care—what the best clinical care is for each condition.
The second is about system design—what do we know about how to design a system so that good care is the outcome.
The third is a strategy to change our current system while we are still working so that it becomes the best system
And we put this all in a strategy to learn them—a learning model, the collaborative.
Learning
Model

23. System Change Concepts Why a Chronic Care Model?
Emphasis on physician, not system, behavior
Characteristics of successful interventions weren’t being categorized usefully
Commonalities across chronic conditions unappreciated.
1) In the past, deficiencies were attributed to bad physicians who just didn’t do the right thing. The emphasis needs to be on the system and the care it delivers.
2) The literature hasn’t been organized in such a way that makes it easy to understand what health care providers were doing and how they were doing it to achieve better results. We need to read the literature and look at who was on the team, what they did, how they interacted with each other and the patient, what visit intervals were like, etc. Clinical trials are more than just one drug vs. another. They create a system of regular, routine care and follow-up, with standardized assessments.
3) Research is primarily condition-specific because of funding sources. We need to be able to provide care in a framework that is similar no matter if the patient has asthma, depression or multiple sclerosis. We need to do this for our own sanity and for our patient’s who can’t be expected to deal with a system where they have 5 case managers, 7 providers and charts in every one of those places.

24. 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
The chronic care model grew in the following way. It began with attempts to improve care for diabetes at Group Health Cooperative, which has approximately 20,000 patients with diabetes. The improvements were based on a careful reading of the literature. In 1996, GHC was funded to bring together international experts in chronic illness care and charged them with finding the commonalities in the ways they provided good care. This seemed like a useful strategy to continue, and RWJF funded a planning grant which had an international advisory committee who did two things: help develop the model and nominate ideal chronic illness care programs. 72 programs were interviewed and the information checked against the developing model. Fifteen of the organizations were site visited. The elements of the successful programs were captured in the chronic care model.
Geriatrics is the interesting area, because care for geriatrics needs to be condition-neutral. Patients have many chronic conditions.
Planning grant published as:
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66
First diabetes collaborative published in:
Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care: a collaborative approach. MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative of Puget Sound, 1730 Minor Ave, Suite 1290, Seattle, WA, USA. Jt Comm J Qual Improv Feb;27(2):63-80

25. Essential Element of Good Chronic Illness Care
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
The advisory committee told us that good outcomes are the result of productive interactions between an informed, activated patient (and their family or caregivers) and a prepared, proactive practice team. This is what the chasm report calls continuous healing relationship.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66

26. What characterizes a “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
Let’s look at the two sides of the interaction in more detail.
Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting Population-Based Care Into Practice: Real Option or Rhetoric? J Am Board Fam Pract. 1998;11(2):

27. What characterizes a “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!
We need to help our patients become more involved in their care. We need to allow for cultural and age cohort variations and personal preference in the amount of involvement. Our interactions need to foster the patient’s sense of control and responsibility.
Anderson R. Patient empowerment and the traditional medical model: A case of irreconcilable differences? Diabetes Care. 1995; March. 18(3):
Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002; November. 288(19):
Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M. Living a healthy life with chronic conditions. Bull Publishing, Palo Alto, CA. 2000

28. productive interaction?
How would I recognize a
productive interaction?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
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
This is how you would know good chronic illness care if you saw it.

29. Clinical Information Systems Self- Management Support
Chronic Care Model
Community
Health System
Resources and Policies
Health Care Organization
Clinical Information Systems
Self- Management Support
Delivery System
Design
Decision
Support
Prepared,
Proactive
Practice Team
Informed,
Activated
Patient
Productive
Interactions
Our premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood) Nov-Dec;20(6):64-78.
Improved Outcomes

30. 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
Self-management support: Empower and prepare patients to manage their health and health care.
1) Emphasize the patient’s central role in managing their health. Providers emphasize the patient's active and central role in managing their illness. (Health care team is only with patients a very brief amt. of time.)
2) Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up.
5 A’s is an office-based way to help patients with behavior change.
Assessments include not only knowledge but beliefs and behavior. (Knowledge isn’t enough to change behavior. We need to understand more about what patients value and what they do.)
Advice needs to be given carefully and linked to things that are important to patients. For example, graphing lowered blood sugars after a patient has successful exercised regularly.
Agree on goals that are important to patients. Goals are usually broken down into smaller steps (typically called action plans) that lead to better outcomes.
Assist with problem-solving by identifying barriers, strategies and social or environmental support.
Arrange a specific follow-up plan. Follow-up is not left to chance and can be done in person, over the phone or via , or by using peers and outreach workers.
Review: Effectiveness of SM training for diabetes Norris et al, Diabetes Care 2001;24:561
Glasgow et al in submission
3) Organize internal and community resources to provide ongoing self-management support to patients.

31. 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
Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support.
Delivery system design is where we all work everyday--(WHO is there and WHAT do they do to contribute to good quality care. This is about HOW we interact with patients.)
1) Sometimes people who work together don’t really work together. We are talking about actually having a team who discusses the work they do and how they are going to do it and how to improve on it. Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting Population-Based Care Into Practice: Real Option or Rhetoric? J Am Board Fam Pract. 1998;11(2):
2) Planned interactions have an agenda, like a routine physical has a known agenda. These can be either 1:1 or in groups. We can use prompts and tools to help set the agenda and not leave out critical parts of the care. McCulloch et al Effective Clinical Practice 1998;1:12-22 and Disease Management 2000;3(2):75-82
3) Many of the effective chronic disease programs use case or care managers, but many of us in clinic settings don’t have a way to make care managers a part of our team. What we can do is to determine what it is the care managers are doing that improved care, and make those tasks part of our system. We also need to reserve these intensive services for patients who really need them, the complex patients, either because of multiple conditions, complicated treatment routines or for psychosocial reasons. Simon et al. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ. 2000;320:550
4) Follow-up is not left to chance. Better outcomes in chronic illness care are due to proactive follow-up by the health care team. In real estate, they say, Location, Location, Location. In chronic illness, it is Follow-up, Follow-up, Follow-up.
Support for telephone follow-up: Nurses increase exercise in elderly primary care pts using phone calls: Journal of Geront: Medical Sciences 2002 vol 57A no 11 M733-M740.
Impact of automated phone calls and nurse calls on diabetes in the VA, RCT Piette et al, Diabetes Care 2001;24:202 (better HbA1c, more lipid testing, fewer sx, better satisfaction)
5) Give care that patients understand and that fits with their cultural background. This goes beyond providing interpretation but being aware of our values, beliefs and communication style, and adapting to meet patient needs.
Since clinical case management is a hot topic, here is a little more detail about what the evidence shows are effective services.

32. 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
Positive results in multiple trials
Don’t have to have a case manager, but looks like do need to provide these functions in the outpatient setting.
Source for negative review of case management for severe mental disorders: Marshall M et al Cochrane Database Syst Review 2000; (2) CD000050

33. 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.
Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences.
Many people think that decision support is only about guidelines, but it is much more than that.
Guidelines can be found at
1) We need to not only have guidelines, but get them off the shelf or the computer screen and use them. Make it hard to do it wrong. Grimshaw & Russell Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317 Good guidelines describe stepped care.
2) Our typical way of interacting with specialists is to send a patient and hope to get a letter back. We need ways to work more closely together. Some examples are by practice agreements or by sharing team members. Go beyond traditional referral letters to real-time consultation and exchanges. Quinn et al. Overcoming turf battles: developing a pragmatic, collaborative model to improve glycemic control in patients with diabetes. Jt Comm J Qual Improv 2001;27:255
Katon et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA Apr 5; 273(13):
3) We know lots of ways that don’t change provider behavior, like lecturing you (which I am doing now. The good news is that a collaborative like you will be working in, has been shown to change the ways systems work and improve outcomes for patients. Providers and care teams benefit from problem or case-based learning, academic detailing, modeling by expert providers.) Wagner EH, et al. Quality improvement in chronic illness care: a collaborative approach.. Jt Comm J Qual Improv Feb;27(2):63-80
4) Another thing we can do is to inform patients of guidelines pertinent to their care. (Sometimes written as “Expectations for Care” to let patient know what their care should be like.) An example is a wallet card for diabetes. This information is designed to encourage patient participation in all aspects of care, from shared decision-making to adjusting treatment according to shared care plans.

34. Clinical Information System
Provide reminders for providers and patients.
Identify relevant patient subpopulations for proactive care.
Facilitate individual patient care planning.
Share information with providers and patients.
Monitor performance of team and system.
Clinical information system: Organize patient and population data to facilitate efficient and effective care.
Many of you may think of this as a registry, but these information systems range from card files to fully functional electronic health records and everything in between. Whatever our system, we need it to perform be able to do these things for us.
1) Provide timely care reminders for providers and patients (Our CIS will prompt reminders to perform needed labs or exams.)
2) Identify relevant patient subpopulations can be identified for proactive care. (Such as to notify all the smokers of a new cessation program, invite patients to a group meeting, or alter medications if some new therapy is shown to be beneficial.)
3) Individual patient care planning is facilitated by the information system. (Care plan is stored and can be adjusted as patient changes their routine and care is adjusted.)
4) Information can be shared with patients and providers. Print outs, care summaries, and communications from distant sites are all ways to increase the efficiency and quality of care we can provide.
5) Monitor performance of practice team and care system—the CIS provides us feedback on how we are doing by provider, clinic or entire system. This feedback loop is valuable information for us to learn from what we are testing and the changes we are trying in our settings.

35. 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.
Health care organization: Create a culture, organization and mechanisms that promote safe, high quality care.
1)Visible support for leaders is believed to be critical for ongoing success. Ovretveit et al. Quality collaboratives:lessons from research. Qual Saf Health Care 2002;11: Senior leaders provide support by visiting clinical sites, reviewing monthly reports, providing resources and problem-solving for innovators. This support of change in pursuit of better quality care becoes part of the culture of the organization and everyone has a role in quality.
2) Some QI strategies work. Langley and colleagues have categorized what they learned from helping organizations institute improvements. References on Effective QI: Walshe & Freeman Qual Saf Health Care 2002 Mar;11(1): Langley et al: The Improvement Guide, Jossey Bass, 1996
3) Encourage open and systematic handling of errors and quality problems to improve care . Safety has been a rallying cry for inpatient care and is becoming a concern in outpatient care. The system needs to be open and honest about handling errors in care and shortcomings in quality. IOM Quality chasm
4) Examples of provider incentive: Medical Assistance Administration (Medicaid) in Washington state pays for group clinical visits for asthma and diabetes when lead by an MD or ARNP. Includes assessment, treatment planning, group discussion on prevention of exacerbations or complications, proper use of medications and monitoring and living with chronic illness, Q&A, BP, wt, one on one to gather data and review individual treatment plan. Pays ~$20, 4 times/yr.) Reward care teams for quality of care, not just productivity. Not always monetary but through recognition, attending CME. Not just physician providers.
Bonuses for MDs for quality care: employers and health plans starting bonus programs, $ per patient for BP control, lower lipids, blood sugar. Some programs reward establishing a registry, providing pt education and having regular follow-up (Boston Globe 11/7/2002, p A1) Endsley et al FPM March 2004.
5) Develop agreements that facilitate care coordination within and across organizations. Work with local hospitals, VNS, social service agencies in an open and coordinated manner. IOM Quality Chasm

36. 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.
Community: Mobilize community resources to meet needs of patients.
1) Encourage patients to participate in effective community programs. This means you need to first know what they are. A good example of an effective program based in the community is the Chronic-Disease Self-Management Program developed by Stanford. It is a 6 week scripted curriculum delivered by lay people with chronic illness. Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, González VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Medical Care, 37(1):5-14, 1999.
Lorig et al. Medical Care 39: , (follow-up data)
2) Form partnerships with community organizations to support and develop interventions that fill gaps in needed services One of the most common partnerships is for safe exercise programs. In the Seattle area, the University of Washington partnered with Group Health Cooperative and Senior Services to make “Lifetime Fitness” exercise program available in senior centers and community meeting rooms throughout the area.
3) Advocate for policies to improve patient care
Another potential way is to have health plans work together. In several states, health plans have coordinated chronic illness guidelines, measures and care resources throughout the community. This makes it much easier for practicing providers to work with more than one plan. (Washington, Oregon, Kansas City)

37. 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 CM, Valk GD, Franse LV, Schellevis FG, van Eijk JT, van der Wal G. Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care Aug;24(8):
Evidence that just guideline didn’t change process or outcome in asthma and angina:
Eccles et al BMJ 2002;325:941 computerized guidelines, RCT in UK
Renders et al, Diabetes Care, 2001;24:1821

38. Impact of disease management on control (number of positive trials)
Provider education = 12/32
Provider feedback = 9/23
Provider reminders = 6/14
Patient education = 24/55
Patient reminders = 6/16
Patient financial incentives =3/4
This is a review of 118 programs which met Cochrane collab criteria for asthma, back pain, CAD, chronic pain, CHF, COPD, depression, ESRD, hyperlipidemia, HTN, RA and OA. Nearly half of the programs used more than one intervention.
Weingarten et al BMJ 2002;325:925
Weingarten et al BMJ 2002;325:925

39. 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
Positive results in multiple trials
Don’t have to have a case manager, but looks like do need to provide these functions in the outpatient setting.
Source for negative review of case management for severe mental disorders: Marshall M et al Cochrane Database Syst Review 2000; (2) CD000050

40. 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
Based on Cochrane collab, we would expect this trial to be positive because it covered the elements of successful chronic illness care.
Olivarius N, Beck-Nielsen H., Andreasen A, Horder M., and Pedersen P. Randomised controlled trial of structured personal care of type 2 diabetes mellitus. BMJ. 2001, 323(7319):
Olivarius et al. BMJ 10/01

41. Planning Productive Interactions for Chronic Conditions
For Example: Diabetic Needs
Additional Diagnoses*
45%
Functional Limits**
50%
> 2 Symptoms***
35%
Not Good Health Habits
30%
Or you might choose to think about the care of a patients with chronic diseases, such as diabetes.However, don’t fall into a trap. A disease management program aimed only at improving a hemoglobin A1C will miss the mark. These patients often have multiple diagnoses, functional limits and symptoms.
Source: John Wasson, data from howsyourhealth.com
*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%)

42. 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

43. 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
Median age for all regions of the world (except sub-Saharan Africa) will approach age 70 by the year 2030.
Tobacco currently causes 4 million deaths annually in the world, and by 2030 will cause 10 million deaths each year if the rate of tobacco consumption does not decline.
Heart disease is the leading cause of death in every region of the world except sub-Saharan Africa, where HIV/AIDs affects a quarter of the population.
W.H.O. looked at the CCM and adapted it to the developing world.
W.H.O. Innovative Care for Chronic Conditions, 2002

44. Conmmunity is Critical Source of Care and Support
The policy environment is now the biggest ellipse. The patient-provider interaction has a new partner, the community supporters, forming a triad.
More detail…

45. Things we know as “bullets” under the chronic care model are now found at the policy level, the community and the organizational level.

46. Applying the CCM to prevention
Similarities:
Require regular attention to behavior change
Are population-based
Require planned care and active follow-up
Use decision guides and occur in primary care
Require patient involvement
Require provider training
Community linkages are helpful
Source: Glasgow et al Does the Chronic care model serve also as a template for improving prevention Milbank Quarterly 2001;79:

47. Applying the CCM to prevention
Differences:
Prevention visits are less frequent
Changing behaviors to prevent something may be different than when have an illness
Prevention may not be as well reimbursed
Benefits of prevention more difficult to perceive
Few people specialize in prevention
1. Yearly or every few year visits for prevention.
People may not perceive the threat of an illness they don’t have. Chronic illness behavior change involves the medical care routine and may be more complex than behavior change to prevent illness.
Prevention may not be considered part of medical care, and reimbursement may be less
Healthy populations don’t recognize the economic or health benefits of prevention
We rely on community organizations to address prevention care.
Source: Glasgow et al Does the Chronic care model serve also as a template for improving prevention Milbank Quarterly 2001;79:
Glasgow et al Milbank Quarterly 2001;79:579

48. Contact us:
thanks

49. Functional and Clinical Outcomes:
Congestive Heart Failure -- Rich et al
Health System: Barnes-Jewish Hospital St. Louis
Community
Self- Management Support: Standardized educational program
Clinical Information Systems
Delivery System
Design:
Nurse case manager
Hospital and home visits Telephone F/U
Decision
Support: Guidelines Ongoing consultation with cardiologist
Informed,
Activated
Patient
Prepared,
Proactive
Practice Team
Productive
Interactions
Functional and Clinical Outcomes:
Reduce readmission rate
Non-significantly lower mortality
Increased quality of life
Rich et al, NEJM 1995

50. Multidisciplinary Group Visits
Cooperative Health Care Clinic
Health System: Kaiser-Permanente Colorado
Community
Self- Management Support: Group Education Peer Interaction
Clinical Information Systems
Patient Notebook
Delivery System
Design:
Multidisciplinary Group Visits
Decision
Support: Provider Education, Clinical Priorities
Informed,
Activated
Patient
Prepared,
Proactive
Practice Team
Productive
Interactions
Functional and Clinical Outcomes:
Decreased emergency room use, repeat admits, specialist use Increased calls to nurses, decreased calls to doctors Increased immunizations Increased satisfaction for patient and provider
Beck et al, JAGS 1997;45:543

51. Functional and Clinical Outcomes:
Health Enhancement Project
Health System: GHC and PacifiCare
Clinical Information Systems:
Electronic Chart and Follow-up System
Community: Northshore Senior Center
Self- Management Support: Individual and
Group Interactions
Decision
Support: Evidence-based Protocols
Delivery System
Design:
GNP visits, peer mentors
Informed,
Activated
Patient
Prepared,
Proactive
GNP reporting to PCP
Productive
Interactions
Functional and Clinical Outcomes:
Decreased disability and increased activity levels
Decreased hospitalization
Increased socialization
Decreased psychoactive medication use
Leveille et al, JAGS 1998;46:1191

52. Functional and Clinical Outcomes:
The Diabetes Clinical Improvement Roadmap
Health System: Group Health Cooperative of Puget Sound
Community
Self- Management Support: Right Track Notebook/Phone Program,
Lorig Support Groups
Decision
Support:
Guidelines,
Expert Team,
Provider Education
Delivery System
Design:
Multidisciplinary Group Visits,
Planned visits,
Retinal Screening Program
Clinical Information Systems
On-line Registry,
Practice Reports, Reminders,
Patient Summaries
Informed,
Activated
Patient
Prepared,
Proactive
Practice Team
Productive
Interactions
Functional and Clinical Outcomes:
Increased retinal, foot and renal screening rates,
Increased Hemoglobin A1c testing,
Increased proactive/planned care,
Reduced costs,
Increased satisfaction for patient and provider
McCulloch et al Eff. Clin Prac 1998;1:12,
Dis Mgmt 200;3:75

53. Functional and Clinical Outcomes:
Ongoing Depression Treatment
Health System: 12 PCPs in US metro and non-metro)
Community
Self- Management Support: office nurse provided info on treatment options, readiness intervention, tx effectiveness assessment
Clinical Information Systems
Pt roster with tx summaries, feedback to care team
Decision
Support:
AHCPR guidelines
Psychia-trist review and advice on tx adjust
Delivery System
Design:
PCP, nurse and office staff all involved.
Monthly contact with pts by phone via nurse
Informed,
Activated
Patient
Prepared,
Proactive
Practice Team
Productive
Interactions
RCT 12 sites, 211 adults, new treatment episodes.
Phone calls averaged 12 minutes, nurses were able to reach 94 % of intervention patients, averaged 5 contacts in first 6 months and 6.9 contacts in months 9-24.
Functional and Clinical Outcomes:
Incr. Use of antidepressants
Incr. Use of counseling
80% remission in 2 yrs (40% for usual care)
Higher role functioning
Rost et al BMJ 2002;325:934

54. Functional and Clinical Outcomes:
Diabetes Nurse Case Management
Health System: Prudential Jacksonville
Community
Self- Management Support: 1:1 visits with trained RN, follow-up support,
pt. Ed class
Delivery System
Design:
case mgmt. RN in clinic, routine meetings with PCP
Clinical Information Systems
diabetes registry, patient monitoring logs
Decision
Support:
Detailed manage- ment algorithms, specialist consult.
Informed,
Activated
Patient
Prepared,
Proactive
Practice Team
Productive
Interactions
Functional and Clinical Outcomes:
decreased HbA1c no increase in adverse events improved self-reported health status
Aubert et al Ann Int Med 1998;129:605

55. Non-specific Nurse Case Management
Health System
Community
Health Care Organization
Regional health system
Resources and Policies
developed a guide
referred patients
Clinical Information Systems
used a nursing documentation program
Delivery System
Design
intensive
case mgmt
(home visit
every 6 wks, monthly phone calls)
Self- Management Support
trained to
emphasize patient
strengths
Decision
Support
no clinical guidelines
consult with
geriatrician
and team
Problem-Centered
Interactions
Age 70+ requiring assistance with ADLs
In ED in past year
Randomized to Case Management or Usual Care
Care rendered by nurse with “minimum of two years geriatric nursing experience” and 3 days training
Each full-time nurse managed patients
Over 10 months, each patient received 10 home visits and 8 phone calls on average
Ave. age 81
59% female
60% live alone
69% report health as fair or poor
Care coordination
Supporting transitions
Resource finding
Patient/
Caregiver
Case manager
linked to others
Gagnon et al, JAGS
1999; 47:
Increased hospitalization
No change in functional status

56. Asthma Resource Center
Health System
Community
Health Care Organization
Regionalized health system (UK)
Resources and Policies
No links to ER or hosp.
Asthma Resource Center in hospital
Clinical Information Systems
Not described
Delivery System
Design
Asthma nurse
working with
practice nurse who runs asthma clinic
Self- Management Support
Standardized information
Decision
Support
Thoracic Society Guidelines.
Six teaching
sessions with nurses
RCT of 41 office practices, all patients with asthma 15-50yo. Nurses educated patients about guidelines
Some description lacking in study, not clear what visit routine was like or how visits conducted.
lengthened intervention, still no effect in 3 yrs.
Unmotivated
Patient/Family
Practice Nurse working in isolation
Ineffective
Interactions
No improvement in QOL, ER use or anti-inflammatory use
Premaratne et al BMJ
1999;318:

57. Stages of Coping with Data
Stage 1: The data are wrong.
Stage 2: The data are right, but it’s not a problem.
Stage 3: The data are right, it’s a problem, but it’s not my problem.
Stage 4: The data are right, it’s a problem, and it’s my problem.
Source: Don Berwick, plenary address IHI International Forum on Quality in Health Care Orlando FL Dec 2002

58. "Ultimately, the secret of quality is love
"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