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

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Presentation on theme: "The Chronic Care Model Presenter Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation."— Presentation transcript:

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

2 Living with chronic illness is like piloting a small plane

3 To get safely to their destination pilots need: Self-Management Support Effective Clinical Management Treatment Plan Close Follow-up Flight instruction Preventive Maintenance Safe Flight Plan Air Traffic Control Surveillance

4 Usual care works well if your plane is about to crash

5 Three Biggest Worries About Having A Chronic Illness (Age 50 +) 1.Losing Independence 2.Being a Burden to Family or Friends 3.Not Being Able to Afford Needed Medical Care

6 Percent Somewhat or Strongly Disagreeing With Statements Age Age 65+ Government programs are adequate to meet the needs of people with chronic medical conditions Health insurance pays for most of services chronically ill people need People with chronic medical conditions receive adequate medical care 65% 55% 66% 47% 43% 52%

7 Number of Chronic Conditions per Medicare Beneficiary Number of Conditions Percent of Beneficiaries Percent of Expenditures % 95%

8 Prevalence of chronic conditions 10.3 % have heart disease 23% have HTN 9.1% have asthma 6.2% have diabetes Prevalence of HTN and diabetes increased in Hispanics and blacks

9 The IOM Quality report: A New Health System for the 21st Century

10 The IOM Quality Report: Selected Quotes The current care systems cannot do the job. Trying harder will not work. Changing care systems will.

11 IOM Report: Six Aims for Improving Health Systems Safe - avoids injuries Effective - relies on scientific knowledge Patient-centered - responsive to patient needs, values and preferences Timely - avoids delays Efficient - avoids waste Equitable - quality unrelated to personal characteristics

12 Recent literature on care Insert here Recently published literature that demonstrates the gap between what we know and what we do.

13 Diabetes 69% had HbA1c test in last year 63% had feet checked 64% had dilated eye exam Among uninsured, only 62% had HbA1c, 48 % a foot exam, 49% an eye exam)

14 Asthma 48% take prescribed medications 29% report using steroid inhalers 17% report having a peak flow meter at home

15 Use of statins in pts with MI 60% of patients over age 65 with a history of a heart attack were on a cholesterol- lowering medication 33% knew the result of their most recent cholesterol measurement Ayanian et al Arch Inter Med 2002;162:1013

16 Hypertension care in US Over 16,000 patients 27% had hypertension 15-24% had controlled hypertension 27-41% unaware that they had hypertension 25-32% had treated uncontrolled hypertension 17-19% aware of hypertension but it was untreated NEJM 2001;345:

17 Physician treatment practices for hypertension 41% had not heard of JNC guidelines JNC guidelines recommend treatment to 140/90 43% of MDs would not start therapy unless systolic >160 and 33% would not start treatment unless diastolic >95 Most would choose ACE for first drug Hyman et al Arch Inter Med 2000;160:2281

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

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

20 Systems are perfectly designed to get the results they achieve The Watchword

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

22 Evidence-based Clinical Change Concepts A Recipe for Improving Outcomes Learning Model System Change Concepts System change strategy

23 System Change Concepts Why a Chronic Care Model? Emphasis on physician, not system, behavior Characteristics of successful interventions werent being categorized usefully Commonalities across chronic conditions unappreciated.

24 Model Development Initial experience at GHC Literature review RWJF Chronic Illness Meeting -- Seattle Review and revision by advisory committee of 40 members (32 active participants) Interviews with 72 nominated best practices, site visits to selected group Model applied with diabetes, depression, asthma, CHF, CVD, arthritis, and geriatrics

25 Essential Element of Good Chronic Illness Care Informed, Activated Patient Productive Interactions Prepared Practice Team

26 What characterizes a prepared practice team? Prepared Practice Team At the time of the visit, they have the patient information, decision support, people, equipment, and time required to deliver evidence-based clinical management and self-management support

27 What characterizes a informed, activated patient? Patient understands the disease process, and realizes his/her role as the daily self manager. Family and caregivers are engaged in the patients self-management. The provider is viewed as a guide on the side, not the sage on the stage! Informed, Activated Patient

28 Assessment of self-management skills and confidence as well as clinical status Tailoring of clinical management by stepped protocol Collaborative goal-setting and problem-solving resulting in a shared care plan Active, sustained follow-up Informed, Activated Patient Productive Interactions Prepared Practice Team How would I recognize a productive interaction?

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

30 Self-management Support Emphasize the patient's central role. Use effective self-management support strategies that include assessment, goal- setting, action planning, problem-solving and follow-up. Organize resources to provide support

31 Delivery System Design Define roles and distribute tasks amongst team members. Use planned interactions to support evidence- based care. Provide clinical case management services. Ensure regular follow-up. Give care that patients understand and that fits their culture

32 Features of case management Regularly assess disease control, adherence, and self-management status Either adjust treatment or communicate need to primary care immediately Provide self-management support Provide more intense follow-up Provide navigation through the health care process

33 Decision Support Embed evidence-based guidelines into daily clinical practice. Integrate specialist expertise and primary care. Use proven provider education methods. Share guidelines and information with patients.

34 Clinical Information System Provide reminders for providers and patients. Identify relevant patient subpopulations for proactive care. Facilitate individual patient care planning. Share information with providers and patients. Monitor performance of team and system.

35 Health Care Organization Visibly support improvement at all levels, starting with senior leaders. Promote effective improvement strategies aimed at comprehensive system change. Encourage open and systematic handling of problems. Provide incentives based on quality of care. Develop agreements for care coordination.

36 Community Resources and Policies Encourage patients to participate in effective programs. Form partnerships with community organizations to support or develop programs. Advocate for policies to improve care.

37 To Change Outcomes (e.g., HbA1c) Requires Fundamental Practice Change Interventions focused on guidelines, feedback, and role changes can improve processes Interventions that address more than one area have more impact Interventions that are patient- centered change outcomes. Renders et al, Diabetes Care, 2001;24:1821

38 Impact of disease management on control (number of positive trials) Provider education = 12/32 Provider feedback = 9/23 Provider reminders = 6/14 Patient education = 24/55 Patient reminders = 6/16 Patient financial incentives =3/4 Weingarten et al BMJ 2002;325:925

39 Features of case management Regularly assesses disease control, adherence, and self-management status Either adjusts treatment or communicates need to primary care immediately Provides self-management support Provides more intense follow-up Provides navigation through the health care process

40 Impact of Planned Care and Collaborative Goal-Setting Randomized Danish GPs to diabetes intervention groups Intervention group trained to provide regular goal-setting in periodic structured visits with their diabetic patients Study team provided guidelines, training, reminders, and regular feedback Mean HbA1c significantly better years later Olivarius et al. BMJ 10/01

41 Planning Productive Interactions for Chronic Conditions Additional Diagnoses*45% Functional Limits**50% > 2 Symptoms***35% Not Good Health Habits30% *Arthritis (34%), obesity (28%), hypertension (23%),cardiovascular (20%), lung 17%) ** Physical (31%), pain (28%), emotional (16%), daily activities (16%) *** Eating/weight (39%), joint pain (32%), sleep (25%), dizzy/fatigue(23%), foot (21%), backache (20%) For Example: Diabetic Needs

42 Advantages of a General System Change Model Applicable to most preventive and chronic care issues Once system changes in place, accommodating new guideline or innovation much easier Early participants in our collaboratives using it comprehensively

43 The Growing Burden of Non-communicable Disease Rapidly aging population Increased environmental riskssmoking, changed diet, increasing inactivity, air pollution Double jeopardy: still fighting infectious disease and malnutrition while experiencing impacts of chronic disease W.H.O. Innovative Care for Chronic Conditions, 2002

44 Conmmunity is Critical Source of Care and Support

45

46 Applying the CCM to prevention Similarities: Require regular attention to behavior change Are population-based Require planned care and active follow-up Use decision guides and occur in primary care Require patient involvement Require provider training Community linkages are helpful

47 Applying the CCM to prevention Differences: Prevention visits are less frequent Changing behaviors to prevent something may be different than when have an illness Prevention may not be as well reimbursed Benefits of prevention more difficult to perceive Few people specialize in prevention Glasgow et al Milbank Quarterly 2001;79:579

48 Contact us: thanks

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

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

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

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

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

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

55 Patient/ Caregiver Problem-Centered Interactions Case manager linked to others Increased hospitalization No change in functional status Delivery System Design intensive case mgmt (home visit every 6 wks, monthly phone calls) Decision Support no clinical guidelines consult with geriatrician and team Clinical Information Systems used a nursing documentation program Self- Management Support trained to emphasize patient strengths Health System Resources and Policies developed a guide referred patients Community Health Care Organization Regional health system Non-specific Nurse Case Management Gagnon et al, JAGS 1999; 47:

56 Unmotivated Patient/Family Ineffective Interactions Practice Nurse working in isolation No improvement in QOL, ER use or anti-inflammatory use Delivery System Design Asthma nurse working with practice nurse who runs asthma clinic Decision Support Thoracic Society Guidelines. Six teaching sessions with nurses Clinical Information Systems Not described Self- Management Support Standardized information Health System Resources and Policies No links to ER or hosp. Asthma Resource Center in hospital Community Health Care Organization Regionalized health system (UK) Asthma Resource Center Premaratne et al BMJ 1999;318:

57 Stages of Coping with Data Stage 1: The data are wrong. Stage 2: The data are right, but its not a problem. Stage 3: The data are right, its a problem, but its not my problem. Stage 4: The data are right, its a problem, and its my problem.

58 "Ultimately, the secret of quality is love. You have to love your patients, you have to love your profession, you have to love your God. If you have love, you can work backward to monitor and improve the system." Donabedian


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