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The Chronic Care Model. Developed by Ed Wagner, MD, MPH and colleagues MacColl Institute for Healthcare Innovation Group Health Cooperative of Puget Sound.

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Presentation on theme: "The Chronic Care Model. Developed by Ed Wagner, MD, MPH and colleagues MacColl Institute for Healthcare Innovation Group Health Cooperative of Puget Sound."— Presentation transcript:

1 The Chronic Care Model

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

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

4 n “The current care systems cannot do the job.” n “Trying harder will not work.” n “Changing care systems will.”

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

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

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

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

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

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

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

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

13 Delivery System Design Clinical Information Systems Health System Resources and Policies Community Health Care Organization Chronic Care Model Family Education & Self- Management Support Evidence-based guidelines Provider education Referrals and specialist expertise Guidelines for patients Decision Support

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

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

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

17 Delivery System Design Clinical Information Systems Health System Health Care Organization Chronic Care Model Family Education & Self-Management Support Partnerships Key school contact identified Input Educational services available Decision Support Community Resources and Policies

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


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