1. Dr. Shondra Williams, Jefferson Community Health Center
Chronic Care in a PCMH
Julie Peskoe, PCDC
Dr. Shondra Williams, Jefferson Community Health Center
This presentation will quickly run through the basics of Chronic Care management to make sure that we’re all on the same page, then we’ll have a presentation by Dr. Shondra Williams from Jefferson Community Health Centers in Lousiana on how her 4 health centers transitioned from acute care to chronic care. Finally, we’ll have a discussion of some of the challenges that you all face with the chronic care model and hopefully have a discussion of strategies and solutions.

2. Building Blocks of High Performing Primary Care Consistent with CCM
Just as a refresher – the CCM reuqires many of these building blocks of high performing primary care. Name which ones?

3. Chronic Disease Care
Chronic conditions such as diabetes, depression, asthma and cardiovascular disease are the major cause of illness, disability, and death in the United States today.
In 2010, the medical costs of chronic disease amounted to 75% of healthcare spending.
Why do we focus on chronic disease? Why is NCQA, Joint commision so concerned?
In 2010 the medical costs chronic disease amounted to 75% of health care spending.

4. Percent of types of visits seen in primary care nationwide-2006
From Thomas Bodenheimer-Caring for People with Chronic Illness presentation
Chronic Care is a Primary Care problem
Chronic care happens in the primary care setting. Take a look – 76% of the asthma visits seen nationwide were seen not in a specialists office but in a primary care setting. Often patients in CHC have not just one of these chronic conditions but severa.

5. Traditional Delivery system
Responds primarily to acute, and urgent healthcare problems
Focus: diagnosis, ruling out serious conditions, and relieving symptoms.
Less focus: education, prevention and helping patients learn to care for themselves better.
So, with our traditional system of care which responds to acute and urgent health problems there is less focus on education, prevention and helping patients learn to care for themselves. There simply isn’t enough time in the visit for the clinician by herself to do all she needs to do for chronic care management.
According to one study there are about 100,000,000 people in the united states with at least one chronic condition. About ½ of them have more than one condition.

6. The Case for Chronic Care Model
To deliver high-quality chronic care to all our patients in a way that a busy community health center can manage, we need to rethink how we deliver the care
The Chronic Care Model provides us with a framework for thinking about this, and essential tools to help improve our processes
In particular, a focus on care teams and use of registries can help you get started on redesigning your care delivery to better meet the needs of chronically ill patients.
The CCM is a framework for thinking about how to redesign your care model to address the realities of the types of patients we’re seeing. Focus on team care, where the clinician isn’t doing it all, using registries, empaneling patients, proactively reaching out to patients, is a more effective model for delivering high quality care to our patients.

7. Chronic Care Management
Those with chronic conditions, better served by systematic approach that emphasizes:
Patient self-management
Care planning with mulit-disciplinary team
Ongoing assessment and follow-up
To make it all work need engaged patients, working with a multidisciplinary team that has clear divisions of responsibilities. It absolutely doesn’t work when there is no clear understanding of who is doing what and the patient isn’t engaged.

8. Key Components of Chronic Care Model
Informed, Activated Patient
Productive Interactions with Prepared, Proactive Practice Team
Decision Support
Clinical Information Systems
Delivery System Redesign
Self-Management Support
Patient needs to be engaged in care. To do that you need time and resources
Team needs time to plan visits
Decision support to serve as reminders and build evidence based guidelines into care. Also a way to build trust and measure performance
Clinical information systems remind care team members to comply with practice guidelines, provide feedback to the care team on how patients are doing and registries for planning patient care and population health.
For people with chronic disease – self management can be taught to patients (diet, exercise and self-monitoring)

9. Care Management
How do we make the Chronic Care Model work in a busy, stressed, community healthcare practice?
So how do you make it work in a busy health center. It can involve some pretty radical change. How do you go from an acute focus to chronic focus? Individual provider visit to team visit? Provider responsibility to team responsibility? Waiting for the patients to call to proactively scheduling? Easiest way to move is incrementally – can’t change an entire system overnight. With Jefferson, who we’ll hear from in a bit – their first step was to introduce care managers and the concept of a very basic registry. Moved on from there. We’ve seen other health centers start with just one chronic condition, develop protocols, workflows and team responsibilities around that one condition before branching out to other chronic conditions.

10. Simplify Registries Teams
Simplify the Chronic Care Model from Thomas Bodenheimer “Caring for People with Chronic Illness” presentation
Decision support
Clinical practice guidelines
Clinician education
Clinical information systems
Clinician feedback
Reminders/Alerts
Registries
Delivery system redesign
Planned visits
Care management
Primary care teams
Self-management support
Simplify
Registries
Teams
The basic, most essential building blocks for introducing the chronic care model involve registries and teams. Registries to identify who is in need of chronic care services. Can start with the highest risk and then teams to address their needs.

11. Registries
Registries: Lists of patients your practice is responsible for that includes clinical information
Example: diabetes
Date of last A1c, LDL, blood pressure, eye exam, foot exam, microalbumin
Results of A1c, LDL, blood pressure, etc.
What patient education was done?
Registries can get mores sophisticated over time. Start with basic. Can even start with paper lists of highest risk patients.

12. Registries and teams
A registry is useless unless someone systematically manages it!
Care gap = Lack of medical attention/care
Process care gap:
60 year old woman: no mammogram for 5 years
Patient with diabetes: no HbA1c for 1 year
Outcome care gap:
Patient with diabetes: HbA1c > 9
Patient with hypertension: Blood pressure 160/95
Requires a team to do this work
Once you have a registry, need to work it. Can’t be one clinician alone. Requires a team and clear guidelines on who does what. Who sees the highest risk, who gets the patient education, the pedometer,

13. Teams Large teams are difficult - Smaller teams or teamlets are easier
Divide the practice into small teams/teamlets
Each teamlet responsible for a panel of patients
Same teams always work together,
Patients know them and they know the patients
Bodenheimer and Laing, Ann Fam Med 2007;5;457;Bodenheimer T. Building Teams in Primary Care, Parts 1 and 2, California Healthcare Foundation,
Bodenheimer likes smaller teams so that patients know team members and team members build trust. Really hard to use team concept effectively if team members don’t trust each other. If I’m the clinician and I am now being asked to have my medical assistant handle patient education, I need to know that I can trust that she’s been well trained.

14. Three chronic care functions of primary care team
Panel management: Making sure every patient with a chronic condition is identified proactively and has all their evidence based care done on time
Health Coaching: making sure every patient with a chronic condition understands their disease, is assisted with health behavior change and medication adherence
Complex Care management: Intensive management of high risk patients with multiple chronic conditions
So, once you’ve established the teams what do they do?

15. Care Manager Role in CCM
Relatively new job
Defined differently by different people
Ultimately, you have to shape the role to fit your center’s needs, and the needs of your patient population
Not all patients need care management
The focus of a Care Manager is usually on needs of chronically ill patients
Some health centers the care manager focuses on a specific set of patients – diabetics or cardiovascular disease. In others care manager is called in to assist with specific patients in need of additional services or referrals.

16. Care Manager Role in CCM
Registry work/Panel management
Pre-Visit Planning
Planned visits
Health Coaching/Care Plans
Linking patients to community resources
Coordinating transitions of care
Provide educational materials

17. Care Manager
Establish what care management tasks need to be routinely completed for the chosen patient population
Decide who is capable of, or could be trained to perform those tasks
Everyone should work to the “top of their license”
Establish what tasks and/or staff members care manager will oversee, as opposed to what they will do
How to define the role? After you’ve established tasks need to be specific on goals – what is panel size, what’s being done directly by CM, where will it be documented?

18. Using the care team to expand the 15 minute provider visit
Pre-Visit
Huddles
Agenda Setting
Medication reconciliation
Ordering routine services
History Taking
Visit
Diagnosis and management
Build relationship with patient
Post-Visit
Soliciting Patient Concerns
Closing the Loop
Goal Setting/Care Plan
Navigating the System
Between Visits
Telephone calls or s to patient to see how they are doing
Health coach or care manager consults with provider on how patient is doing
In CCM the 15 minute provider visit is only part of the interaction with the patient. There is also a pre-visit component, post visit, and work between visits.

19. System Redesign
Pre-Visit
Huddles
Agenda Setting
Medication Reconciliation
Ordering routine services
History Taking
Visit
Diagnosis and management
Build relationship with patient
Post-Visit
Soliciting Patient Concerns
Closing the Loop
Goal Setting/Care Plan
Navigating the System
Between Visits
Telephone calls or s to patient to see how they are doing
Health coach or care manager consults with provider on how patient is doing
Neither necessary, nor desireable, to launch entire model at one time!
Use PDSA methodology to test new model
Use PDSA, start slow and manageable.

20. From Theory to Practice: Transition to the PCMH Model

21. Overview of Jefferson Community Health Care Centers, Inc.
Established in 2004
Grew from 1-4 clinic locations in 10 years
2 of 4 locations grew as a result of 2 disasters-Hurricane Katrina & BP Oil Spill
Serve nearly 14,000 unique patients annually
Nearly a $10m budget
Recognitions: PCMH Level 3-September, 2012
Joint Commission Accreditation-2011

22. Corporate Office Our Clinical Practice Avondale River Ridge Marrero
Lafitte
Marrero

23. Primary Care & Preventive Care Dental
Service Offerings
Primary Care & Preventive Care
Dental
Specialty Services: Behavioral Health, Pediatrics, Podiatry, Obstetrics, Gynecology, & Occupational and Environment Medicine

24. Transition to Care Coordination
Beacon Community
Identified a Team Lead
Team Development
Small Groups to conceptualize essential elements
Policy Development
Collaboration with other Partners to inform policy development
Emphasis was focused on Chronic Care
Diabetic Huddles
Teaching Tool Development
Referral into Care Management
Team Approach to Healthcare

25. Our Process… Challenges Successes
By In
A1C Control
Staffing Challenges
Sustained Results
Transitions
Team Development
Resources
Communication Improvement
Time
Patient Satisfaction
Chronically Ill Patient Population
PCMH concepts have translated to enhanced preventive health screenings
Economics of Patient Population
*Medication Management
*Cost of Visits
*Transportation
Care Coordinator Follow-up
Productivity vs. Financial
Partnerships & Coaching
EMR Optimization-MU

26. Timeline for Transition
January, 2012
September, 2012
March, 2012
Project
Champion was Identified

27. Major Milestones EMR Optimization PCMH-Level 3 Recognition
Clinical Staff are working to the top of their ability

28. Staff Considerations Job Descriptions Salary Requirements
Care Management Role
Care Coordinator Role
Flow Coordinator

29. Executive Perspective
Supporting the Clinical Leadership
Staffing
EMR Optimization
Scheduling-Open Access
Shifting and Allocating Resources
Balance of Quality vs. Quantity

30. Challenges with CCM in a CHC
Realities of a busy health center
Change Management
Staff buy in
Limits of EMR
Patient acceptance
Other competing priorities
Cost of delivering care this way

31. Questions
How does your organization handle patients with chronic care management?
Where do you think your organization will be in a year?
What works well? What doesn’t work?
How do you measure and document the work of care teams?
How do you build trust in teams?
How does leadership communicate goals?
How do you make the roles of team members clear and transparent?
How does payment/revenue affect your organizations implementation of the chronic care model? What about that 10th building block of high functioning primary care?