2. 1 The Chronic Care Model: Implications for HIV Care and Training October 1, 2007 Kathleen A. Clanon, MD, FACP Pacific AETC

3. 2 Goals for Talk: 1. Describe the elements of the Chronic Care Model and its rationale. 2. Describe practical applications of the Chronic Care Model in HIV specific settings. 3. List possible training settings and audiences for which Chronic Care Model content might be appropriate.

4. 3 The Usual Visit  Patient is in the room, chart in the slot. Nurses and doctors don’t confer.  MD reviews the chart for 30 seconds before entering the room.  Patient’s goal is to get a form filled out; MD is worried about new detectable viral load.  HCM flow sheet is half filled out.  MD drones through adherence rant.  Patient leaves, MD notes later that ppd and pap were overdue.

5. 4 Evolution of HIV Care Disease Care  Acute  Reactive  Focus on dx/rx  Customized care  Spiritual  MD role central Health Care  Chronic  Proactive  Focus on behavior  Standardized care  Practical  Pt role central Kathleen Clanon, MD 2007 19802010

6. 5 Tyranny of the Urgent: What doesn’t get done when we do disease care instead of health care?

7. 6 Tyranny of the Urgent: What Doesn’t Get Done  Adherence counseling  Prevention counseling  Family planning  Nutrition  Stress reduction training  Mental health  Smoking cessation  Substance abuse treatment  Vaccinations  Cancer screening  HCV treatment

8. 7 Hepatitis A & B Vaccination Practices for Ambulatory Patients with HIV-Infection Methods - 9 Clinic (HOPS) Sites - N = 1071 in study - Analysis of HOPS data base DesignResults From: Tedalid EM et al. Clin Infect Dis 2004;38:1478- 84.

9. 8 One Example: Smoking  Many PWHIV smoke (52% vs 23% in gen pop)  Smokers on HAART have morbidity (ADC = 36%) and mortality (53%)compared to nonsmokers.  Well-documented programs and interventions for smoking cessation are available. Does your clinic have a smoking cessation program for HIV positive patients? Feldman J Am J Public Health 2006;96(6):1060

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11. 10 Not Just HIV: Preventive Care Quality  Over 4000 patient visits by 138 family physicians  Patients were up to date on 55% of routine screening tests 55% of routine screening tests 24% of immunizations 24% of immunizations 9% of health behavior counseling 9% of health behavior counseling Stange et al. Prev Med 2000;31:167

12. 11 Do the Math A primary care physician with a panel of 2500 average patients (not HIV) would need to spend:  7.4 hours per day to do all recommended preventive care. [Yarnall et al. Am J Public Health 2003;93:635]  10.6 hours per day to do all recommended chronic care. [Ostbye et al. Annals of Fam Med 2005;3:209] Slide adapted from Bodenheimer.

13. 12 Impact of the Aging Epidemic: More Chronic Illnesses Prevalence of other chronic illnesses in VA patients with HIV Hypertension40% Hyperlipidemia22% Diabetes17% Fultz SL et al, CID 2005 Sep 1; 41:738-43

14. 13 HIV Providers’ Comfort Treating Other Chronic Illnesses Comfortable treating chronic illness DMHTN Hyper- lipidemia Depression General Internists seeing HIV in Gen Med Clinic (n=66) 98% 49% Gen Internists seeing HIV in ID Clinic (n=33) 61%79%73%42% ID Specialists in ID Clinics (n=51) 57%73%71%33% Fultz SL et al, CID 2005 Sep 1; 41:738-43.

15. 14 What Do These Data Demonstrate?  Overfocus on the clinician- patient dyad as the unit of care.  Underutilization of the team (esp. the patient) in care.  Insanity of the 15 minute visit. Slide adapted from Bodenheimer.

16. 15 My Favorite Quote from the Government “Improvements in care cannot be achieved by further stressing current systems of care. The current systems cannot do the job. Trying harder will not work.” IOM 2001: Crossing the Quality Chasm

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18. 17 Genesis of the CCM: Why Research Results and Real Life Don’t Match  Rushed practitioners not following established practice guidelines “The gap between knowing and doing.”  Lack of care coordination  Lack of active follow-up to ensure the best outcomes  Patients not trained to manage their own illnesses successfully

19. 18 History of the Chronic Care Model Developing the Model  Improving Chronic Illness Care Program, MacColl Institute for Healthcare Innovation, Seattle.  RWJF Chronic Illness Meeting Developing a Change Strategy  IHI Breakthrough Series, Dallas 1999 Disseminating the Practice  Model applied with diabetes, geriatrics, asthma, CHF, CVD, HIV/AIDS, and depression in >500 health care organizations via collaboratives.

20. 19 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Practice Level

21. 20 Informed, Activated Patient/Client Productive Interactions Prepared, Proactive Care Team Improved Outcomes Case man.; Integrate MH care AETC training; Dissem DHHS Guidelines CAREware, labtracker; Aries Client advocacy, peer mentoring All Parts Food bank, volunteers, child care. Community RWHATMA Continuum of Care HIV Chronic Care Model

22. 21 Domains of the Chronic Care Model Self-management Support Patient sets goals and is in charge of care. Education focuses on problem-solving skills. Peer mentoring and support. Adherence and prevention programs. Community Involvement Form partnerships with ASO’s. Address stigma and myths. Delivery System Design Planned and group visits. Case management. Integrating mental health/subs abuse/medical care..

23. Domains of the Chronic Care Model Decision Support (Provider Knowledge and Behavior) Embed guidelines into daily care. Share guidelines with patients, case managers AETC activities Clinical Information System Provide reminders of care for providers and pts. Feed aggregate data into CQI system. Share appropriate info between partner orgs. Health Care Organization/Grantee Encourage open handling of errors. Support improvement at all levels of the org. Set and monitor goals in chronic care outcomes for the organization.

24. 23 Does the CCM Improve Outcomes?  It’s a model, not a single intervention.  Meta-analysis of 112 studies of four chronic illnesses: asthma, CHF, Type II DM, and depression.  “Interventions with at least one CCM element had consistently beneficial effects on clinical outcomes and processes of care across all conditions studied.” Tsai, A.C. et al “A meta-analysis of interventions to improve care for chronic illnesses.” AJ Managed Care 8/05

25. 24 HIV: Why Might the CCM Work?  Dangerous chronic illness with available, effective treatment.  Treatment is difficult and lasts over years and decades.  Treatment requires sustained behavior change on part of patient.  Gap between knowledge and outcomes.

26. 25 CCM in Action: Two Dimensions  Patient Self-Management  Delivery System Design

27. 26 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Practice Level

28. 27 Patient Self-Management  Goal setting  Assessing conviction and confidence  Action planning  Peer mentoring and advocacy

29. 28 Can “Our Patients” Self-Manage? “ Patients with chronic conditions self- manage their illness. This fact is inescapable. Each day, patients decide what they are going to eat, whether they will exercise, and to what extent they will consume prescribed medications.” Bodenheimer, et al 2002 JAMA 288(19); 2470

30. 29 Traditional Patient Education vs. Self-Management Education Traditional Patient Education Self-Management Education Content Taught Disease-specific information and technical skills Problem-solving skills that can be applied to chronic conditions in general Definition of the problem Inadequate control of disease Patient formulates the problem which may/may not be directly related to disease Theoretical construct underlying the education Disease-specific knowledge produces behavior change and leads to improved clinical outcomes Patient’s self-efficacy (learned through setting short-term action plans) leads to improved clinical outcomes Goal Compliance with behavior changes taught to patient to improve clinical outcomes Increased self-efficacy to improve clinical outcomes Educator Health professional Health professional or peer leader and other patients in the group

31. 30 Action Plan (Example) 1. Goals: Something you WANT to do: Begin exercising_______ 2. Describe: How: Walking________ Where: Around the block What: 2 times Frequency : 4 x/wk When: After dinner____ 3. Barriers: Have to clean up; bad weather 4. Plans to overcome barriers: Ask kids to help; get rain gear 5. Conviction 8 & Confidence 7 ratings (0-10) 6. Follow-Up: Next visit – 2 months

32. 31 Delivery System Design  Planned visits Expanding staff roles Using information systems  Group visits  Case management  Integrated care: One-stop-shop

33. 32 Planned Medical Visits  “an encounter… that focuses on overall patient goals and other aspects of care that are not usually delivered during an acute-care visit.”  AAFP, June 2005

34. 33 Planned Medical Visits  “Standing meeting” of staff (no chairs, no donuts) at beginning of day to review each patient  Team members are alerted and on the same page (adherence educators, case managers, etc.) Tasks are shared.  Print out of what HCM the pt needs is on the front of the chart with overdue items flagged.  Materials are in room(vaccines, pap materials, forms and education materials).

35. 34 Using Staff Differently  May be peers, health educators, M.A.s. They take the lead on health promotion.  Meet with pts pre-, during-, or post- the clinician visit.  Advantages are: Patients connect with staff differently than with M.D. Cheaper staff can take more time with pts. Staff like it!

36. 35 Group Visits  Medical visits, scheduled for 2.5 hours.  10-12 patients scheduled.  Clinician, case managers, adherence educators, benefits advisers all present.  Starts with education, group questions. Focus on self-management, prevention and HCM.  Providers pull pts out for brief one-on- ones as group session continues.

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38. 37 Implementing the CCM: What Are the Barriers?  Time  Turf  Trust  Turnover

39. 38 Implementing the CCM: What Are the Barriers?  Payers may not reimburse for group work or prep work  Difficulty of changing big systems  HIPAA  Tradition of individualism in medicine. (We are the biggest obstacle.)

40. 39 What Are the HIV-specific Barriers?  Stigma and disclosure concerns  No patient-accessible measure of daily health (similar to glucose or peak flow)  Groups most affected by HIV have social, educational challenges  Our pts deal with chaos; low show rates and crises mean staff need to be consistent and protect the planned visit time.

41. 40 Resources Websites: www.improvingchroniccare.org www.collaborativeselfmanagement. org www.collaborativeselfmanagement. org www.nqc.org Contacts: Kathleen A. Clanon, MD, FACP kclanon@jba-cht.com