1. Redesigning Chronic Illness Care: The Chronic Care Model
Ed Wagner, MD, MPH
MacColl Institute for Healthcare Innovation
Center for Health Studies
Group Health Cooperative
Improving Chronic Illness Care
A national program of the Robert Wood Johnson Foundation
IHI National Forum December 10, 2007

2. Chronic Illness in America
More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them.
Despite annual spending of well over $1 trillion and significant advances in care, one-half or more of patients still don’t receive appropriate care.
Gaps in quality care lead to thousands of avoidable deaths each year..
Patients and families increasingly recognize the defects in their care.
The magnitude of the problem:
45% of the U.S. population suffers from one or more chronic illnesses, and over 60 million (21% of the population) have multiple conditions.
Anderson G, Horvath J. The Growing Burden of Chronic Disease in America, Public Health Reports, May–June Accessed February 6, 2007, at:

3. Chronic Illness and Medical Care
Primary care dominated by chronic illness care
Clinical and behavioral management increasingly effective BUT increasingly complex
Inadequate reimbursement and greater demand forcing primary care to increase throughput—the hamster wheel
Unhappy primary care clinicians leaving practice; trainees choosing other specialties
Loss of confidence in primary care by policy-makers and funders
But, there are new models of primary care and growing interest in changing physician payment to encourage and reward quality

4. What Patients with Chronic Illnesses Need
A “continuous healing relationship” with a care team and practice system organized to meet their needs for:
Effective Treatment (clinical, behavioral, supportive),
Information and support for their self-management,
Systematic follow-up and assessment tailored to clinical severity,
More intensive management for those not meeting targets, and
Coordination of care across settings and professionals

5. Why are we doing so poorly?
The IOM Quality Chasm report says:
“The current care systems cannot do the job.”
“Trying harder will not work.”
“Changing care systems will.”

6. What’s Responsible for the Quality Chasm?
A system oriented to acute disease that isn’t working for patients or professionals

7. What kind of changes to practice systems improve care?

8. Randomized trials of system change interventions: Diabetes
Cochrane Collaborative Review
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

9. The Effectiveness of QI Strategies: Findings from a Recent Review of Diabetes Care
The Shojania article, also included in the earlier summary slide, illustrates the variety of QI strategies attempted and their effectiveness.
Shojania, K. G. et al. JAMA 2006;296:

10. Toward a chronic care oriented system
Reviews of interventions in other conditions show that practice changes are similar across conditions
Integrated changes with components directed at:
use of non-physician team members,
planned encounters,
modern self-management support,
Intensification of treatment
care management for high risk patients
electronic registries
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

11. 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

12. What distinguishes good chronic illness care from usual care?
Informed,
Activated
Patient
Prepared
Practice
Team
Productive
Interactions
The essential element of good chronic illness care is a productive interaction, versus current interactions that tend to be frustrating for both patients and providers. An interaction can be a face-to-face visit, a phone call or an message. Productive means that the work of evidence-based chronic disease care gets done in a systematic way, and patient needs are met.
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

13. productive interaction?
How would I recognize a
productive interaction?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
Assessment of self-management goal attainment and confidence as well as clinical status
Adherence to guidelines
Tailoring of clinical management by stepped protocol (Treat to target)
Collaborative goal-setting and problem-solving resulting in a shared care plan
Planning for active, sustained follow-up
The overarching definition of a productive interaction is one that assures that patient needs for evidence-based clinical and behavioral care information and support to become better self-managers, and monitoring over time are met.

14. What characterizes an “informed, activated patient”?
They have goals and a plan to improve their health, and the motivation, information, skills, and confidence necessary to manage their illness well.
To maximally improve outcomes, we need a different kind of patient. “Informed” means the patient has sufficient information to become a wise decision-maker related to their illness. Patients also need to be “activated” by understanding the importance of their role in managing the illness.

15. Self-Management Support
Goal
To help patients take a more active role and be more competent managers of their health and healthcare.
Let’s look at each of the elements in a little more detail:
Self-Management support: Empower and prepare patients to manage their health and health care.
Emphasize the patient’s central role in managing their health. Providers reinforce the patient's active and central role in managing their illness.
Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow-up. Evidence now strongly suggests that to achieve optimal outcomes in most chronic illness, we must improve the patients ability and interest in managing their own condition. The best tested strategy to support self-management employs the 5A’s.
Assessment includes 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 linked to scientific evidence, not provider biases.
Agree on goals that are important to patients and actions to reach them.
Assist by identifying barriers and problem-solving to deal with them.
Arrange a specific follow-up plan including utilizing internal and community resources to provide ongoing self-management support to patients.
One example of an effective program based in the community is the Chronic-Disease Self-Management Program developed by Stanford. It is a six-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, 1999; 37(1):5-14.

16. Community Resources and Policies
Goal
To help patients access effective and useful services and resources in the surrounding community.
Community: Mobilize community resources to meet needs of patients.
There are many important resources and services for patients that are not part of most medical systems: peer support groups, exercise programs, nurse educators, or dieticians often aren’t in small practices.
Encourage patients to participate in effective community programs. This means you need to first know what and where they are.
Form partnerships with community organizations to support and develop interventions that fill gaps in needed services. For example, 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.
Advocate for policies to improve patient care such as insurance coverage for diabetes supplies.
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.

17. What characterizes a “prepared” practice team?
Practice team and interactions with patients organized to help patients reach clinical targets and self-management goals. .
The other side of the productive interaction is a practice team that is organized, trained, and equipped to conduct productive interactions.

18. Delivery System Design
Goal
To organize practice staff, schedules and other systems to assure that all patients receive planned, evidence-based care.
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.)
Most successful chronic care interventions involve increased clinical involvement of the non-physician members of the care team. We are talking about actually having a team who discusses the work they do, 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):
Planned interactions have an agenda, like a routine physical or a prenatal visit. Planned visits can be either 1:1 or in groups. We can use a registry 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
Patients with complex needs, or engaged in an acute transition or exacerbation, often benefit from more intensive attention. The use of a clinical case or care manager, usually a nurse or a pharmacist, has been shown to be effective in diabetes, CHF, depression, and other illnesses.
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.
Piette et al. Impact of automated phone calls and nurse calls on diabetes in the VA, Diabetes Care 2001; 24:202 (better HbA1c, more lipid testing, fewer sx, better satisfaction)
Patients should be routinely asked to “teach back” to check comprehension and if they are comfortable with the plan. Providers need to check in with patients to make sure that the interaction style is compatible with their cultural norms, values, and beliefs.

19. Decision Support
Goal
To assure that clinicians and other staff have the training, scientific information and system support to routinely provide evidence-based (adhere to guidelines) and patient-centered care.
Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences.
Decision support begins, but cannot end, with the dissemination of evidence-based guidelines. Distribution of guidelines alone has minimal impact. What does work is the integration of guidelines into the flow of clinical decision making.
We need to not only possess guidelines, but we must get them off the shelf or the computer screen and use them in decision making.
Grimshaw & Russell Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342:1317
Our typical way of interacting with specialists is to refer a patient and hope to get a letter back. Some examples include shared care, 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):
McCulloch DK, Price M, Hindmarsh M, Wagner E. Improvement in Diabetes Care Using an Integrated Population-based approach in a Primary Care Setting. Disease Management 2000; 3(2):75-82.
Providers and care teams benefit from problem or case-based learning, academic detailing or modeling by expert providers.
Another thing we can do is to inform patients of guidelines pertinent to their care so they understand why a particular test, procedure, or screening is being performed.

20. Clinical Information System
Goal
To assure that clinicians and other staff have ready access to patient information on individuals and populations to help plan, deliver and monitor care.
Clinical information system: Organize patient and population data to facilitate efficient and effective care.
The crucial factor in improving chronic illness care is a clinical database that has the critical information that one needs to have a productive interaction (a registry). Even in the absence of a full electronic medical record (EMR), many registries can perform all the functions shown on the slide. Conversely, some EMRs may not be able to perform these functions so practices should be careful what information systems they employ to manage their patients’ care.

21. Health Care Organization
Goal
To assure that practices within the organization have the motivation, support and resources needed to redesign their care systems.
Health care organization: Create a culture, organization, and mechanisms that promote safe, high-quality care.
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:
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
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.
Reward care teams for quality of care, not just productivity. Not just physicians and not always monetary but through recognition, attending CME.
Develop agreements that facilitate care coordination within and across organizations. Work with local hospitals, VNS, and social service agencies in an open and coordinated manner. IOM Quality Chasm

22. Does the CCM Work?
The Evidence Base

23. Organizing the Evidence
Randomized controlled trials (RCTs) of individual interventions to improve chronic care
Studies of the relationship between organizational characteristics and quality improvement
Evaluations of the use of the CCM in Quality Improvement
RCTs of CCM-based interventions
Cost-effectiveness studies
The following slides discuss each of these types of evidence in turn.

24. 1: RCTs of interventions to improve chronic care results
Studies in other conditions confirm that the elements found effective in diabetes care apply to other chronic conditions as well.
STUDY SPECIFICS
A review of systematic reviews demonstrates that integrated care programs generally have positive outcomes. The most commonly used components of integrated care programs include: self-management support, patient education, case management, multidisciplinary patient care team, and clinical feedback/reminders/education. Authors caution that inconsistent definitions of interventions and outcomes are prevalent throughout the literature and, if ignored, can lead to inappropriate conclusions about the effectiveness of programs in meta-analyses.1
One of two reviews of depression treatment in primary care finds that complex interventions using clinician education, enhanced nurse case management, and greater integration between primary and specialty care are effective in improving patient outcomes. Less complex interventions like provider education alone are less likely to be effective.2
Badamgarav and colleagues conducted systematic evaluation of disease management. Lack of a clear definition of “disease management” makes interpreting the findings difficult, but in general they found an improvement in patient satisfaction, adequacy of prescribed treatment, and other quality of care markers. They also found increases in costs associated with hospitalization and treatment costs among the intervention groups as compared to controls.3
A review of quality improvement strategies in hypertension finds that interventions that include team care are associated with the greatest improvement in blood pressure outcomes. Here, team care is defined as the “assignment of some responsibilities to a health professional other than the patient's physician.” Other strategies that proved effective include patient education and self-management support.4
Glasgow and colleagues published a literature review and expert recommendations for future research around diabetes care as part of the Health Care Delivery Work Group. They find that the continued focus on acute illness, rather than proactive chronic care management, is the cause for poor-quality diabetes care processes and outcomes. They cite articles showing that self-management support, improved patient-provider communication, and collaborative goal setting are linked to improved behavioral, biological, and quality of life outcomes. They also cite that a population focus, inclusion of clinician prompts and reminders, and a quality clinical information systems that supports disease registries are helpful tools to improve care.5
A second systematic review of diabetes shows that multifaceted interventions that “facilitate structured and regular review of patients were effective in improving the process of care.” Renders et al finds that studies rarely assess outcomes. Like the studies above, they find that clinician education with performance feedback and use of care teams seemed to improve care.6
A recent Cochrane review of diabetes care finds that in 58 papers with 66 comparisons, quality improvement initiatives that used team changes and those that use case management with the ability to influence physicians’ prescribing patterns showed the largest difference in post intervention HbA1c scores.7
Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care 2005; 17(2):141-6.
Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA 2003; 289(23):
Badamgarav E, Weingarten SR, Henning JM et al. Effectiveness of disease management programs in depression: a systematic review. Am J Psychiatry 2003; 160(12):
Walsh JM, McDonald KM, Shojania KG et al. Quality improvement strategies for hypertension management: a systematic review. Med Care 2006; 44(7):
Glasgow RE, Hiss RG, Anderson RM et al. Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care. Diabetes Care 2001; 24(1):
Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care 2001; 24(10):
Shojania KG, Ranji SR, McDonald KM et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006; 296(4):

25. 2: Studies of the Relationship between Organizational Characteristics and Quality
Studies measure adherence to the CCM via self-assessment or external observer
Analyses either compare high and low performers or correlate degree of CCM implementation with performance
Studies show that quality improves with fuller implementation of the CCM
Most studies cross-sectional; don’t answer the question whether going to trouble of redesigning practice improves performance.
STUDY SPECIFICS
There is a significant relationship between a practice’s primary care orientation and its implementation of the CCM. Specifically, medical groups (as opposed to IPAs) that accept risk for hospitalization costs, use health promotion programs, have an electronic standardized problem list, and are required to report patient process and outcome measures appear to use more chronic care management practices.1
Flemming et al. studied 134 managed Medicare organizations and collected diabetes quality measures (HbA1c, LDL, microalbuminuria and eye exams). They assessed 32 care elements based on the CCM and compared top and bottom quartiles on quality (e.g., HbA1c > 9.5–20% vs. 50%). Top quartile more likely to employ CCM elements, especially: computerized reminders, practitioner involvement on QI teams, guidelines supported by academic detailing, formal self-management programs, a registry.2
Staff participation in practice decisions and optimization of the clinical care team to include non-physician staff can improve the delivery of preventive services. In addition, improved clinical systems such as reminders and patient registries are associated with improved delivery of preventive services.3
Overall, physician organizations have not adopted as many components of the diabetes care management index as we would expect. 47% use one or fewer care management processes. A number of factors were associated with increased use of care management processes: Reporting data to external organizations; receiving income, recognition, or better contracts for quality; improved IT infrastructure; ownership by HMO or hospital system; receiving capitated payments; and large size.4
1. Schmittdiel JA, Shortell SM, Rundall TG, Bodenheimer T, Selby JV. Effect of primary health care orientation on chronic care management. Ann Fam Med 2006; 4(2):
2. Fleming B, Silver A, Ocepek-Welikson K, Keller D. The relationship between organizational systems and clinical quality in diabetes care. Am J Manag Care 2004; 10(12): Hung DY, Rundall TG, Crabtree BF, Tallia AF, Cohen DJ, Halpin HA. Influence of primary care practice and provider attributes on preventive service delivery. Am J Prev Med 2006; 30(5):
4. Li R, Simon J, Bodenheimer T et al. Organizational factors affecting the adoption of diabetes care management processes in physician organizations. Diabetes Care 2004; 27(10):

26. Study of in 20 Texas Primary Care Practices
Several studies have demonstrated a relationship between practice characteristics consistent with the CCM and performance
Study of in 20 Texas Primary Care Practices
Practices evaluated themselves using the ACIC
Researchers reviewed diabetic charts
Analysis looked at relationship between ACIC scores and 10 yr. risk of CHD (HbA1c, BP, LDL, smoking)
Higher ACIC associated with reduction in modifiable CHD risk (full implementation of CCM reduced average risk over 50%).
Parchman et al. Medical Care, Dec. 2007

27. 3: Evaluations of the Use of CCM in Quality Improvement
3 major evaluations - RAND Evaluation of ICIC collaboratives - Landon evaluation of the Health Disparities collaboratives - Chin evaluation of HDC in the midwest
All studies focus on diabetes
Methods differed - RAND compared collab. participants with other practices in the org. - Landon compared entire CHCs that were and were not involved in the HDC with 1 yr. follow-up - Chin looked at entire CHCs involved in the HDC over 4 year period
RAND Evaluation of the Improving Chronic Illness Care was a multimillion dollar evaluation effort sponsored by the Robert Wood Johnson Foundation. Because of the size and robustness of that evaluation, those findings are highlighted separately in the next few slides.

28. 3: RAND Evaluation of Chronic Care Collaboratives
Two major evaluation questions: 1. Can busy practices implement the CCM? 2. If so, would their patients benefit?
Studied 51 organizations in four different collaboratives, 2132 BTS patients, 1837 controls with asthma , CHF, diabetes
Controls generally from other practices in organization
Data included patient and staff surveys, medical record reviews
See for details.

29. 3: RAND Findings Implementation of the CCM
Organizations made average of 48 changes in 5.8/6 CCM areas
IT received most attention, community linkages the least
One year later, over 75% of sites had sustained changes, and a similar number had spread to new sites or new conditions.
STUDY SPECIFICS
Over four-fifths of the organizations implemented some interventions in all six CCM elements. However, there were differences: since many elements of the CCM depend on having a registry of patient, sites worked most intensely on improving information support (24% of all their efforts, on average) and least intensely on developing community linkages (8% of their efforts).1
Pearson ML, et al. Assessing the implementation of the chronic care model in quality improvement collaboratives. Health Serv Res Aug; 40(4):

30. 3: RAND Findings: Patient Impacts
Diabetes pilot patients had significantly reduced CVD risk (pilot > control), resulting in a reduced risk of one cardiovascular disease event for every 48 patients exposed.
CHF pilot patients more knowledgeable and more often on recommended therapy, had 35% fewer hospital days and fewer ER visits
Asthma and diabetes pilot patients more likely to receive appropriate therapy
Asthma pilot patients had better QOL
STUDY SPECIFICS
The 10-year risk of cardiovascular disease was determined using a modification of the U.K. Prospective Diabetes Study risk engine. The baseline 10-year risk was 31% for both cases and controls. At the end of the period, the intervention group had a 2.1% greater reduction in predicted risk.1
Participation in the collaborative for Heart Failure was associated with fewer emergency department visits.2 The RAND team also utilized medical record review to measure performance on 23 predefined quality indicators for sites participating in the heart failure collaborative. Patients from collaborative sites showed greater improvement than control sites for 11 of the 21 indicators, including use of lipid lowering and angiotensin converting enzyme inhibition therapy. When all indicators were combined into a single overall process score, participating sites improved more than controls (17% versus 1%, P _ ). The improvement was greatest for measures of education and counseling (24% versus _1%, P _ ).3
The overall process of pediatric asthma care improved significantly in the intervention group but remained unchanged in the control group (change in process score +13% vs 0%; P < .0001). Patients in the intervention group were more likely than patients in the control group to monitor their peak flows (70% vs 43%; P < .0001) and to have a written action plan (41% vs 22%; P = .001). Patients in the intervention group had better general health-related quality of life (scale score 80 vs 77; P = .05) and asthma-specific quality of life related to treatment problems (scale score 89 vs 85; P < .05).4
The RAND study of adult asthma care had a smaller study population and found process of asthma care improved significantly, as did patient satisfaction with communication, but outcomes were not significantly different from controls.5
1. Vargas R, et al. Can a Chronic Care Model Collaborative Reduce Heart Disease Risk in Patients with Diabetes? JGIM, Pre-published online at: Accessed January 29, 2007
Baker DW, Asch SM, Keesey JW, Brown JA, Chan KS, Joyce G, Keeler EB. Differences in education, knowledge, self-management activities, and health outcomes for patients with heart failure cared for under the chronic disease model: the improving chronic illness care evaluation. J Card Fail Aug; 11(6): PMID:
Asch SM, Baker DW, Keesey JW, Broder M, Schonlau M, Rosen M, Wallace PL, Keeler EB. Does the collaborative model improve care for chronic heart failure? Med Care Jul; 43(7):
Mangione-Smith R, et al. Measuring the effectiveness of a collaborative for quality improvement in pediatric asthma care: does implementing the chronic care model improve processes and outcomes of care? Ambul Pediatr Mar-Apr; 5(2):75-82.
Schonlau M, et al. Evaluation of a quality improvement collaborative in asthma care: does it improve processes and outcomes of care? Ann Fam Med May-Jun; 3(3):200-8.

31. 3: Evaluations of the Health Disparities Collaboratives
Landon evaluation showed process but not outcome improvements in the year following the end of participation
Chin showed process improvements in the following year followed two years later by significant reductions in HbA1c and LDL.
My hunch: Participating practices saw short-term improvements in both process and outcomes (RAND), and the spread of process changes to other practices in the system began shortly thereafter, but was slow and didn’t impact clinic-wide outcomes for another year or two.
STUDY SPECIFICS
Used disease registry, diabetes nurse case managers, and group visits to improve diabetes outcomes in rural, minority populations in Eastern North Carolina. Pre-post findings indicated an increase in patients with self-management goals who received lipid panel, used aspirin and received a foot exam.1
Pre-post examination of Midwestern CHCs’ participation in the Diabetes Health Disparities Collaborative showed increased process measures, like rates of HbA1c measurement, eye examination referral, foot examination and lipid assessment. Mean value of HbA1c also decreased. Survey respondents felt the effort was worth it and successful. Practices struggled in: needing more time, developing a patient registry, staff turnover, more support by senior management.2
Teams implementing CCM as part of the Diabetes BTS collaborative improved their self-management support capabilities, as measured both by self report and objective data. Among heart failure collaboratives, daily self-monitoring of weight by patients improved significantly (19% to 93%) and teams provided education significantly more often to patients.3
Harwell and colleagues supported primary care practices with performance feedback. Practices then did a variety of additional system changes. This cross-sectional study found improvements in some processes – foot examinations, microalbumin testing, dilated retinal examination – but not others like HbA1c testing or LDL-C testing.4
Multiple North Carolina residency practices participated in the BTS collaboratives and implemented strategies across all elements of the CCM. Practices evaluated themselves at base-line and after using the ACIC. Study found that key measures of diabetes care were improved in two-thirds of practices.5
Practices in Wisconsin and Minnesota that implemented planned care and DEMS found that planned care plus use of a disease registry improved care across all 12 performance measures. Planned care alone or in conjunction with DEMS improved metabolic outcomes. DEMS alone improved process measures, but not metabolic outcomes.6
Implementation of the CCM in a rural Pennsylvania practice resulted in significant improvement in adherence to ADA guidelines including 2 HbA1c tests per year, lipid profile, urinalysis, eye exam, and foot exam performed. Mean HbA1c also declined significantly, as did mean HDLc levels. Improvement in three empowerment measures was seen, though it wasn’t significant.7
Among a highly transient, uninsured population, significant improvements in diabetes outcomes including decreased LDL, HbA1c, and Arterial Pressure were observed. 8
Case studies from North Carolina show that participation in the CCM collaborative resulted in improved HbA1c values for diabetics. Factors contributing to success included senior leadership support, physician champions, and multidisciplinary teams. Staff turnover was a barrier.9
A Washington state initiative to conduct state-level collaboratives around diabetes care resulted in some improvement in process and outcome measures in most of the 47 participating teams. Absolute improvement was higher for process measures than for outcome measures. 10
One study used the CCM framework to improve the delivery of diabetes self-management training. They found the framework useful in terms of improving the number of DSMT programs offered, enhancing reimbursement to cover costs, and lowering patients HbA1c –ostensibly by offering more patients self-management support. 11
The implementation of the Chronic Care Model produced different results when used at two different primary care practices in London. One site showed significant improvements in identification and case management of depression; the other did not. Tangible barriers like a primative information technology system, lack of experience with chronic disease management, and the inability to find common meeting time proved serious barriers to the implementation of the project in the second site. Other, intangible barriers which mediated the impact of the CCM at the second site included a lack of staff ownership, participation, and buy-in as well as lack of external support for the elements of the project. 12
Sites participating in the Breakthrough Series Collaborative for HIV/AIDS did not show improvement on process or outcome measures when compared to other clinics that did not participate in the BTS collaborative. The proportion of patients with a suppressed viral load decreased in the intervention group, compared to the control group, but the decrease was not significant. 13
Bray P, Roupe M, Young S, Harrell J, Cummings DM, Whetstone LM. Feasibility and effectiveness of system redesign for diabetes care management in rural areas: the eastern North Carolina experience. Diabetes Educ 2005; 31(5):712-8.
Chin MH, Cook S, Drum ML et al. Improving Diabetes Care in Midwest Community Health Centers With the Health Disparities Collaborative. Diabetes Care 2004; 27(1):2-8.
Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med 2002; 24(2):80-7.
Harwell TS, McDowall JM, Gohdes D, Helgerson SD. Measuring and improving preventive care for patients with diabetes in primary health centers. Am J Med Qual 2002; 17(5):
Landis SE, Schwarz M, Curran DR. North Carolina family medicine residency programs' diabetes learning collaborative. Fam Med 2006; 38(3):190-5.
Montori VM, Dinneen SF, Gorman CA et al. The impact of planned care and a diabetes electronic management system on community-based diabetes care: the Mayo Health System Diabetes Translation Project. Diabetes Care 2002; 25(11):
Siminerio LM, Piatt G, Zgibor JC. Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice. Diabetes Educ 2005; 31(2):
Stroebel RJ, Gloor B, Freytag S et al. Adapting the chronic care model to treat chronic illness at a free medical clinic. J Health Care Poor Underserved 2005; 16(2):
Wang A, Wolf M, Carlyle R, Wilkerson J, Porterfield D, Reaves J. The North Carolina experience with the diabetes health disparities collaboratives. Jt Comm J Qual Saf 2004; 30(7):
Daniel DM, Norman J, Davis C et al. A state-level application of the chronic illness breakthrough series: results from two collaboratives on diabetes in Washington State. Jt Comm J Qual Saf 2004; 30(2):69-79.
Siminerio LM, Piatt GA, Emerson S et al. Deploying the chronic care model to implement and sustain diabetes self-management training programs. Diabetes Educ 2006; 32(2):
Scott J, Thorne A, Horn P. Quality improvement report: Effect of a multifaceted approach to detecting and managing depression in primary care. BMJ 2002; 325(7370):951-4.
Landon BE, Wilson IB, McInnes K et al. Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study. Ann Intern Med 2004; 140(11):

32. 4: Randomized Controlled Trials (RCT) of CCM-based Interventions
6 RCTs covering asthma, diabetes, bipolar disorder, comorbid depression and oncology, and multiple conditions
5 in the US – disease specific, 1 in Australia – multiple diseases
Practice-level randomization
5 of 6 showed significant improvements in patient health
These trials all tested multi-component interventions based on the CCM in primary care.

33. 5: Cost Study Results
Some evidence that improved disease control can reduce healthcare costs, especially for congestive heart failure, asthma (among populations with high ER and hospital use) and uncontrolled diabetes
Better depression control does not appear to reduce healthcare costs, but increases work productivity
Huang et al. showed that HDC participation had a favorable CE ratio
STUDY SPECIFICS
Sustained reductions in HbA1c of 1% or more result in cost savings within one to two years of improvement. Cost savings are highest for individuals with highest HbA1c levels at baseline. Utilization of primary care and specialty care were significantly lower among the “improved’ group, but hospitalization rates were not affected.1
Reviewing 44 articles examining the ROI of DM programs showed that some evidence suggests a positive ROI for CHF and multiple disease conditions. Results were mixed for asthma, diabetes, and depression studies, and depended on what types of costs were included (e.g. productivity).2
Gilmer and O’Connor propose that the elements of disease management that are cost effective include: disease management programs, clinical management, and self-management training. Evidence is still needed to support both the costs and effectiveness of these recommendations.3
Organizational features and improvement strategies differentially affect future health care costs. For example, interventions focusing on the increased use of pharmaceuticals to improve care are associated with increased health care costs. Interventions that focus on clinical meetings, registries, and resource use related to diabetes or heart disease care are associated with lower costs.4
Wagner EH, Sandhu N, Newton KM, McCulloch DK, Ramsey SD, Grothaus LC . Effect of improved glycemic control on health care costs and utilization. JAMA 2001; 285(2):182-9.
Goetzel RZ, Ozminkowski RJ, Villagra VG, Duffy J. Return on Investment in Disease Management: a Review. Health Care Financ Rev 2005; 26(4):1-19.
Gilmer T, O’Connor PJ. Cost Effectiveness of Diabetes Mellitus Management Programs - a Health Plan Perspective. Disease Management & Health Outcomes 2003; 11(7):
Gilmer TP, O'Connor PJ, Rush WA et al. Impact of office systems and improvement strategies on costs of care for adults with diabetes. Diabetes Care 2006; 29(6):

34. Challenges in Implementing the CCM
Practices spent considerable time searching for/developing tools
Some practices felt intimidated by taking on the whole model – asked for a sequence
Many changes were made in ways that were not sustainable logistically or financially (e.g., double data entry)
CCM elements implemented as “special events” rather than part of routine care
Many achieve process improvements but outcomes don’t change

35. Why do practices who have changed their system not see improvements in key outcome measures (e.g., measures of disease control)?
The systems aren’t in place to get every patient to target!
Patients are getting regular planned interactions
Limited ability to intensify management of patients not meeting goals

36. What are the barriers? QI efforts limited to “early adopters”
The hamster wheel
Belief in the quality of one’s practice – i.e. no meaningful measurement
Underdevelopment of practice team
Inability to access or use information technology or non-physician staff to improve patient care
Practice isolation
Fee-for-service reimbursement that doesn’t reward high quality care, in fact discourages it

37. If you could fully implement the Chronic Care Model:
How would the care of your average chronically ill patient be different? How would their experience change?

38. If you could fully implement the Chronic Care Model:
How would the day to day experience of the clinical staff be different? Do you think work satisfaction would change?

39. Contact us:
thanks

40. Self-Management Support and Community Resources
Judith Schaefer, MPH
MacColl Institute for Healthcare Innovation
Center for Health Studies
Group Health Cooperative
Improving Chronic Illness Care
A national program of the Robert Wood Johnson Foundation
IHI National Forum December 10, 2007

41. 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
Since most of the day to day management takes place in the lives of patients and the communities where they live and work, it’s appropriate to first look at the two left most elements of the model where patients spend their time. How do we start where patients are and carry the benefits of optimal medical care out into the community so that patients and families can do the best possible job of managing their chronic conditions?
Improved Outcomes

42. FACTS AND FICTIONS
Diabetes is the leading cause of adult blindness, amputations and kidney failure. True or false?
________________________________________
A. False. Poorly controlled diabetes is the leading cause of adult blindness, amputations and kidney failure.
Let’s examine a perspective that influence the way we interact with patients about their condition. How many of you would agree with this statement? This little change of focus might get us focused in a more productive way, on the roles both patients and clinical teams play in controlling chronic conditions.

43. Setting the Stage for Change
Many of the changes that that patients and families need to make to manage their conditions are ones that require continuous effort over long periods of time. It helps to have support from friends, family, your doctor and nurse. This must be a great group, because I can’t remember the last time I was laughing when I stepped on a scale. Let’s look at the changes required for good care for chronic conditions.

44. Differences Between Acute and Chronic Conditions
Beginning
Rapid
Gradual
Cause
Usually one
Many
Duration
Short
Indefinite
Diagnosis
Commonly accurate
Often uncertain
Diagnostic tests
Often decisive
Often limited value
Treatment
Cure common
Cure rare
This chart was developed by Kate Lorig at Stanford University to help people with chronic conditions understand the difference between acute and chronic conditions. If we have pneumonia or a skiing accident, we have a pretty good chance of being diagnosed and treated rapidly and effectively, but without regular preventive care, a person with diabetes may have no symptoms for years, even though their body is becoming less and less able to use carbohydrates efficiently, and high glucose levels in the blood are doing damage to kidneys and eyes. These are some pretty big differences, but they have some even bigger implications.

45. Differences Between Acute and Chronic Care Roles
Role of Professional
Select and conduct therapy
Teacher/coach and partner
Role of Patient
Lorig 2000
Follow orders
Partner/ Daily manager
The more important point of the comparison between short term and long term diseases is to recognize that the longer timeframe of chronic conditions changes the kind of relationship needed between care providers and patients. With the pneumonia, we expect to be inconvenienced by therapy, and even if it is very inconvenient – bed rest for a week, it won’t last too long and we can put up with it because we expect a cure. We’ll put aside our own preferences, even our own judgment, listen to the doc and do what she says. But when the length of the illness is indefinite and the condition makes normal functioning difficult or impossible, most of the “treatment” is really day to day management, and happens outside the healthcare system - at home. The patient is in charge here. Kate says, “Everybody self-manages. The question is how well they self-manage.” So good self-management benefits from a different kind of relationship between patients and health care professionals. Clinicians offer medical advice much like a teacher or coach. People with chronic conditions and our families carry out the treatments at home through our behaviors. We monitor symptoms and how well the treatment is working, and make decisions about managing treatment in our own environment. The doc is the medical expert, we are the expert on managing day to day. We need help recognizing this difference in order to understand that we need to take a more active role in managing our conditions. Now let’s look at another concept to help set the stage for better self-management.

46. Symptom Cycle Vicious Cycle Disease Fatigue Tense muscles Depression
What is more, we may begin to think that everything is due to the disease, and forget that other factors play a part, unaware that other factors can make symptoms of chronic illness seem worse. We may blame our disease for feeling tired or anxious or tense, and then these problems interact with each other, making everything seem worse. If we understand these other factors, we can learn skills and techniques that help us deal with each of them, even though our chronic disease cannot be cured. The symptom cycle shows these other factors, and the program teaches skills that address them, giving people more control over the effects of their illness and greater chance of leading the lives they choose.
Depression
Stress/Anxiety
Anger/Frustration/Fear

47. “Why wouldn’t a person with diabetes do everything in their power to live long and feel well?” Maybe it has something to do with the finer points of how we interact with them.

48. Persuasion Techniques
Agree that speaker should make the change
Explain why the change is important
Warn of consequences of not changing
Advise speaker how to change
Reassure speaker that change is possible
Disagree if speaker argues against change
Tell the speaker what to do
Give examples of others (other patients, peers, celebrities) who have made similar healthy changes
Although persuasion has some role, it may have some drawbacks.

49. Hagar and many patients probably feel similarly about persuasion.

50. The Patient-Focused Approach
BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job.
KNOW WHAT TO DO. The patient must have a clear and achievable plan for self-management

51. Behavior Change Strategies
Begin with your patient’s interests
Believe that your patient is motivated to live a long, healthy life
Help your patient determine exactly what they might want to change
Develop a reasonable, detailed action plan

52. Self-Management in office practice
Personal Action Plan
1. List specific goals in behavioral terms
2. List barriers and strategies to address barriers
3. Specify Follow-up Plan
4. Share plan with practice team and patient’s social
support
ASSESS :
Beliefs, Behavior & Knowledge
ADVISE :
Provide specific
Information about
health risks and
benefits of change
AGREE:
Collaboratively set
goals based on patient’s
interest and confidence
in their ability to change
the behavior
ASSIST :
Identify personal
barriers, strategies, problem-solving
techniques and
social/environmental
ARRANGE :
Specify plan for
follow-up (e.g., visits,
phone calls, mailed
reminders
Although we call it follow up, this graphic helps us understand that supporting patients in managing their illness is an ongoing cyclical process. Teams start by thinking about visit preparation, what happens in the visit and follow up after the visit, but with practice it all becomes part of the ongoing cycle of care, the continuous healing relationship described in the Quality Chasm report.
Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

53. Community Resources
Encourage patients to participate in effective community programs
Form partnerships with community organizations to support and develop interventions that fill gaps in needed services
Advocate for policies to improve care
Here are the change concepts for community resources. Our changes will be made based on these ideas.

54. Ecological Model of Health Behavior
Family friends and peers
Group medical visits
Community health worker services
Peer-led self management courses
Groups
Peer and professional-led support groups
A trained peer who applies his or her unique understanding of the experience, language and culture of the populations he or she serves to promote healthy living and to help people take greater control over their health and their lives. CHWs are trained to work in a variety of community settings, partnering in the delivery of health and human services to carry out one or more of the following roles:
Providing culturally appropriate health education and information
Linking people to the services they need
Providing direct services, including informal counseling and social support
Advocating for individual and community needs, including actively building individual and community capacity.

55. Promotoras/Community Health Workers
Community health workers also known as promotoras, offer culturally appropriate health coaching and provide a valuable link between people from varied cultural and ethnic groups and their healthcare system. They can become the eyes and ears of the clinician in the community.

56. Peer Led Workshops

57. Outreach
Community health workers can take health information and support out to people where they live and work.

58. Organizations Second “level of influence”—organizations
Leveraging changes within organizations
Tasty Fork
Lay health educators at worksites
Healthy breakroom
Walking patient visits
Linkages with organizations/ departments
Referrals to community exercise center with incentives for continued participation
Sharing intake data across health and social services to aid referrals and seamless care
Shared positions
Participatory program planning through a Diabetes
Community Council
· Use of a Circle Model of community organizing for
designing diabetes self management activities
· Case management for enrollees of the Full Circle
Diabetes Program
· Living in Balance chronic disease self management
workshops led by trained members of the Diabetes

59. Partnering Relationships
collaborating
involvement
cooperating
commitment
More complex partnerships take more resources
1—put you in my brochure (BCI)
2—reciprocal referrals—(Campesinos)
3—plan together so service complement—ODHC
4—full integration--MAIC
coordinating
resources
networking

60. Environment and Policy
Third “level of influence”—environment and policy
Advocacy for food choices in grocery stores
Placing educational materials in libraries
Participation in community events, coalitions and partnerships

61. Walkable Neighborhoods/ Cyclovia
Advocacy for walkable towns - Latin America’s Bicycle Sundays, 100,000 families

62. It Takes a Region

63. A Tour of the Model: Clinical Information Systems and Decision Support
Brian Austin
December
Improving Chronic Illness Care is supported by The Robert Wood Johnson Foundation
Grant # 48769
IHI National Forum December 10, 2007

64. Clinical Information Systems Self- Management Support
The 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
You are
here
Informed,
Empowered
Patient
Productive
Interactions
Open with reminding audience of where they are in the Chronic Care Model. Mention that information systems are the glue that holds all of the system redesign work together because without it you can never be sure who your patients are, what care they are receiving and how the changes you make in other areas of the model are actually impacting outcomes.
Improved Outcomes

65. Clinical Information Systems
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.
The crucial factor in improving chronic illness care is a clinical database that has the critical information that one needs to have a productive interaction (a registry). Even in the absence of a full electronic medical record (EMR), many registries can perform all the functions shown on the slide. Conversely, some EMRs may not be able to perform these functions so practices should be careful what information systems they employ to manage their patients’ care.

66. Barriers to CIS use Lack of perceived value
Competing business and productivity demands
Lack of office flow expertise
Lack of information support
Lack of leadership support
Convince nay-sayers with practical demonstrations of how CIS facilitates improved care.
Competing demands need to be addressed by senior leaders so that CIS work receives equal billing.
Teams need to understand how their daily flow works so that fitting the registry into the process is seamless versus an add-on.
Again, senior leaders need to free up IT support to facilitate CIS use and spread

67. Whatever you use should be able to deliver information that supports:
What is the Issue?
Functionality!
Whatever you use should be able to deliver information that supports:
population planning
clinical summaries at the visit
individual care planning
reminders
performance feedback

68. A Recent Product Comparison
CHCF’s Better Ideas Conference 2006

69. Necessary functions for chronic care
be organized by patient; not disease, but responsive to disease populations
contain data relevant to clinical practice
assist with internal and external performance reporting
guide clinical care first, measurement second!

70. Computerized Reminders Fleming et al. Am J Managed Care 2004 10: 934
Organizational characteristics of Medicare Managed Care Plans by Diabetes Quality
Characteristic
High performing Plans
Low performing Plans P
HbA1c >9.5
20%
49%
Use of a Registry
78%
40%
.02
Any Use of an EMR
50%
25%
.11
Computerized Reminders
39% 5%
.01
Fleming et al. Am J Managed Care : 934

71. Modeling the Impacts of IT on Diabetes Quality: Changes from Baseline
HbA1c
SBP
Cholesterol
Disease Management
- 0.24%
- 5 mm
-11 mg/dl
Registries
-0.50%
- 1 mm
- 31 mg/dl
Decision Support
-0.28%
+4 mm
-5 mg/dl
A computer model was created to project the impact of IT-enabled disease maangement on care processes, outcomes and medical costs for patients with type 2 diabetes. Several technologies were modeled (registries, comp. decisions support, remote monitoring)
Nationally, diabetes registries over 10 years saved $14.5 billion, ($1,016 per enrolled patient)
computerized decision support saved $10.7 billion
Integrated provider-patient systems save $16.9 billion
Bu et al. Diabetes Care 2007; 30:1137

72. Keys to Success from Others That Have Implemented Registries
Everyone, including senior leadership understands the clinical utility and supports the time involved in upkeep.
Data forms are clear, data entry role is assigned, data review time allotted.
Data entered and retrieved are clinically relevant, and used for patient care first, and measurement second.
Data can be shared with patient to improve understanding of treatment plan.

73. Patient Expectations for Access to Their Records is Growing
89% of respondents would like to be able to review their medical records.
Two-thirds would like electronic access, including 53% of Americans 60 and over
91% think it is important to review what doctors write in their chart.
84% would like to check for errors in their chart.
Two-thirds of the public (65%) is interested in accessing their own personal health
information electronically. This interest spans demographic groups – with a
majority (53%) of Americans 60 and older and high proportions of minority groups,
including African-Americans and Latinos, expressing interest.
 Large majorities see a number of benefits of accessing information online, which
could lead to a reduction in health care costs. For example, nearly nine in 10
Americans (88%) say online records would be important in reducing the number of
unnecessary or repeated tests and procedures they undergo.
 Americans express strong concern that their information may be used for purposes
other than their own care. Eight in 10 Americans (80%) say they are very
concerned about identity theft or fraud or the possibility of their information getting
into the hands of marketers (77%).
 Americans believe they could gain more control over their health care by using
electronic personal health records. For example, ninety percent say it would be
personally important to track their symptoms or changes in health care online.
Phone survey of 1,003 adults nationwide Nov funded by Markle Foundation

74. A Patient View of an EMR

75. 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.
Decision support begins, but cannot end, with the dissemination of evidence-based guidelines. Distribution of guidelines alone has minimal impact. What does work is the integration of guidelines into the flow of clinical decision making.
We need to not only possess guidelines, but we must get them off the shelf or the computer screen and use them in decision making.
Grimshaw & Russell Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342:1317
Our typical way of interacting with specialists is to refer a patient and hope to get a letter back. Some examples include shared care, 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):
McCulloch DK, Price M, Hindmarsh M, Wagner E. Improvement in Diabetes Care Using an Integrated Population-based approach in a Primary Care Setting. Disease Management 2000; 3(2):75-82.
Providers and care teams benefit from problem or case-based learning, academic detailing or modeling by expert providers.
Another thing we can do is to inform patients of guidelines pertinent to their care so they understand why a particular test, procedure, or screening is being performed.

76. What is evidence-based medicine?
Evidence-based medicine is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable evidence.
The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments.
McMaster University
Note that evidence is modified by patient circumstances and preferences. Guidelines were never meant to dictate the care that is provided, but to inform it and eliminate variation that is detrimental to patient outcome.

77. Evidence-based practice
Customize guidelines to your setting
Embed in practice: able to influence real time decision-making
Flow sheets with prompts
Decision rules in EMR
Share with patient
Reminders in registry
Standing orders
Have data to monitor care
Collins et al. From theory to practice: Identifying authentic opinion leaders to improve care. Managed Care July 2000 p 56-62
Berg et al. Clinical practice guidelines in practice and education. J Gen Inter Med 1997;12(S2):S25-S33.

78. Stepped Care
Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more)
First choice medication
Either increase dose or add second medication, and so on
Includes referral guideline
Stepped care is the main way chronic conditions are treated successfully, including behavioral interventions.

79. Going beyond consultation: integrating specialist expertise
Shared care agreements
Alternating primary-specialty visits
Joint visits
Roving expert teams
On-call specialist
Via nurse case manager
Shared care agreements are used to delineate which provider will do which aspect of care. For example, post MI, the cardiologist may see the patient very soon after discharge to review medications or perform tests, then the primary care physician may provide expertise on lifestyle intervention.
Alternating visits has been used for some patients with depression or asthma.
Joint visits are one of the main ways Group Health Cooperative keeps primary care providers current on diabetes treatment. The specialist and PCP see the patient together. The specialist is part of a roving expert team with a diabetes nurse expert who mentors office nurses. McCulloch et al Eff. Clin Prac 1998;1:12,
Dis Mgmt 200;3:75)
On-call specialists are instructed to respond to pages from primary care even if they are with the CEO. Their on-call time is compensated and valuable to the organization.
Nurse case-managers who are linked with specialists can bring expertise into primary care. (Aubert et al Ann Int Med 1998;129:605)

80. Effective educational methods
Interactive, sequential opportunities in small groups or individual training
Academic detailing
Problem-based learning
Modeling (joint visits)
Academic detailing is borrowing a page from the pharmaceutical reps, but having the content not be a new drug to prescribe, but new evidence-based clinical information.
Problem-based learning is frequently case studies or walking through a case, much as providers are trained.
Modeling allows clinicians to observe another in practice and try the techniques for themselves.
Whitlock et al

81. Effective educational methods
Build knowledge over time
Include all clinic staff
Involve changing practice, not just acquiring knowledge
Result: better diagnosis, continuing care and guideline based care in children with asthma
Evans et al, Pediatrics 1997;99:157
Evans et al, Pediatrics 1997;99:157

82. The Patient as Partner
Principles of CIS &DS

83. Other Choices for Patient Decision Support
PBGH Evaluation of Consumer Decision Support Tools June 2007

84. Ways to share guidelines with patients
Stoplight tools
Expectations for care
Wallet cards
Web sites
Workbooks
There is less of an evidence-base for providing patients with guidelines and the impact that has on care, but there is some evidence that patients who are prepared for a visit receive better care.
Weinberger M, Kirkman MS, Samsa GP, et al. A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. J Gen Int Med. 1995;10:59-66.

85. 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,
Empowered
Patient
Productive
Interactions
Improved Outcomes