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Does The Chronic Care Model Work? A Chartbook created by the staff of: Improving Chronic Illness Care Improving Chronic Illness Care At Group Healths MacColl.

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Presentation on theme: "Does The Chronic Care Model Work? A Chartbook created by the staff of: Improving Chronic Illness Care Improving Chronic Illness Care At Group Healths MacColl."— Presentation transcript:

1 Does The Chronic Care Model Work? A Chartbook created by the staff of: Improving Chronic Illness Care Improving Chronic Illness Care At Group Healths MacColl Institute Supported by The Robert Wood Johnson Foundation Grant # 48769

2 2 I. American Healthcare: A Broken System

3 3 Chronic Illness in America More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them.More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them. Despite annual spending of nearly $1 trillion and significant advances in care, one-half or more of patients still dont receive appropriate care.Despite annual spending of nearly $1 trillion and significant advances in care, one-half or more of patients still dont receive appropriate care. Gaps in quality care lead to thousands of avoidable deaths each year.Gaps in quality care lead to thousands of avoidable deaths each year. Best practices could avoid an estimated 41 million sick days and more than $11 billion annually in lost productivity.Best practices could avoid an estimated 41 million sick days and more than $11 billion annually in lost productivity. Patients and families increasingly recognize the defects in their care.Patients and families increasingly recognize the defects in their care.

4 4 Number of Chronic Conditions per Medicare Beneficiary Number of Conditions Percent of Beneficiaries Percent of Expenditures % 95%

5 5 The IOM Quality report: A New Health System for the 21st Century

6 6 The IOM Quality Chasm Report Conclusions: The current care systems cannot do the job.The current care systems cannot do the job. Trying harder will not work.Trying harder will not work. Changing care systems will.Changing care systems will.

7 7 The Chasm Report: Implications for How to Change Practice If the problem is the system, and not the individual bad apples, then the focus for practice improvement needs to shift.If the problem is the system, and not the individual bad apples, then the focus for practice improvement needs to shift. Need to make the right thing to do the easy thing to do.Need to make the right thing to do the easy thing to do.

8 8 To Change Outcomes Requires Fundamental Practice Change Reviews of interventions in several conditions show that effective practice changes are similar across conditions. Integrated changes with components directed at: influencing physician behavior, influencing physician behavior, better use of non-physician team members, better use of non-physician team members, enhancements to information systems, enhancements to information systems, planned encounters planned encounters modern self-management support, and modern self-management support, and care management for high risk patients care management for high risk patients

9 9 II. The Chronic Care Model

10 10 Evidence-based Clinical Change Concepts A Recipe for Improving Outcomes Learning Model System Change Concepts System change strategy

11 11 System Change Concepts Why a Chronic Care Model? Emphasis on physician, not system, behavior.Emphasis on physician, not system, behavior. Characteristics of successful interventions werent being categorized usefully.Characteristics of successful interventions werent being categorized usefully. Commonalities across chronic conditions unappreciated.Commonalities across chronic conditions unappreciated.

12 12 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

13 13 Essential Element of Good Chronic Illness Care Informed, Activated Patient Productive Interactions Prepared Practice Team

14 14 What characterizes an informed, activated patient? Informed, Activated Patient They have the motivation, information, skills, and confidence necessary to and confidence necessary to effectively make decisions about effectively make decisions about their health and manage it. their health and manage it.

15 15 What characterizes a prepared practice team? Prepared Practice Team At the time of the interaction they have the patient information, decision support, and resources necessary to deliver high-quality care.

16 16 Assessment of self-management skills and confidence as well as clinical status.Assessment of self-management skills and confidence as well as clinical status. Tailoring of clinical management by stepped protocol.Tailoring of clinical management by stepped protocol. Collaborative goal-setting and problem-solving resulting in a shared care plan.Collaborative goal-setting and problem-solving resulting in a shared care plan. Active, sustained follow-up.Active, sustained follow-up. Informed, Activated Patient Productive Interactions Prepared Practice Team How would I recognize a productive interaction?

17 17 Self-Management Support Emphasize the patient's central role.Emphasize the patient's central role. Use effective self-management support strategies that include assessment, goal- setting, action planning, problem-solving, and follow-up.Use effective self-management support strategies that include assessment, goal- setting, action planning, problem-solving, and follow-up. Organize resources to provide support.Organize resources to provide support.

18 18 Delivery System Design Define roles and distribute tasks among team members.Define roles and distribute tasks among team members. Use planned interactions to support evidence-based care.Use planned interactions to support evidence-based care. Provide clinical case management services for high risk patients.Provide clinical case management services for high risk patients. Ensure regular follow-up.Ensure regular follow-up. Give care that patients understand and that fits their culture.Give care that patients understand and that fits their culture.

19 19 Features of Case Management Regularly assess disease control, adherence, and self-management status.Regularly assess disease control, adherence, and self-management status. Either adjust treatment or communicate need to primary care immediately.Either adjust treatment or communicate need to primary care immediately. Provide self-management support.Provide self-management support. Provide more intense follow-up.Provide more intense follow-up. Provide navigation through the health care process.Provide navigation through the health care process.

20 20 Decision Support Embed evidence-based guidelines into daily clinical practice.Embed evidence-based guidelines into daily clinical practice. Integrate specialist expertise and primary care.Integrate specialist expertise and primary care. Use proven provider education methods.Use proven provider education methods. Share guidelines and information with patients.Share guidelines and information with patients.

21 21 Clinical Information Systems Provide reminders for providers and patients.Provide reminders for providers and patients. Identify relevant patient subpopulations for proactive care.Identify relevant patient subpopulations for proactive care. Facilitate individual patient care planning.Facilitate individual patient care planning. Share information with providers and patients.Share information with providers and patients. Monitor performance of team and system.Monitor performance of team and system.

22 22 Community Resources and Policies Encourage patients to participate in effective programs.Encourage patients to participate in effective programs. Form partnerships with community organizations to support or develop programs.Form partnerships with community organizations to support or develop programs. Advocate for policies to improve care.Advocate for policies to improve care.

23 23 Health Care Organization Visibly support improvement at all levels, starting with senior leaders.Visibly support improvement at all levels, starting with senior leaders. Promote effective improvement strategies aimed at comprehensive system change.Promote effective improvement strategies aimed at comprehensive system change. Encourage open and systematic handling of problems.Encourage open and systematic handling of problems. Provide incentives based on quality of care.Provide incentives based on quality of care. Develop agreements for care coordination.Develop agreements for care coordination.

24 24 Advantages of a General System Change Model Applicable to most preventive and chronic care issues.Applicable to most preventive and chronic care issues. Once system changes in place, accommodating new guideline or innovation much easier.Once system changes in place, accommodating new guideline or innovation much easier.

25 25 III. The Evidence Base

26 26 Organizing the Evidence: Look at each of these types in turn 1.Randomized controlled trials (RCTs) of interventions to improve chronic care. 2.Studies of the relationship between organizational characteristics and quality improvement. 3.Evaluations of the use of the CCM in Quality Improvement. 4.RCTs of CCM-based interventions. 5.Cost-effectiveness studies.

27 27 1: Randomized Controlled Trials of Interventions to Improve Chronic Care Most reviews are disease specific.Most reviews are disease specific. Reviews and meta-analyses tend to focus on individual components rather than combined effects.Reviews and meta-analyses tend to focus on individual components rather than combined effects. Diabetes reviews played an important role in CCM development.Diabetes reviews played an important role in CCM development.

28 28 Complex, integrated care, disease management programs show positive effects on quality of care.Complex, integrated care, disease management programs show positive effects on quality of care. Consistently powerful elements include: team care, case management, self-management support.Consistently powerful elements include: team care, case management, self-management support. No consensus on cost-effectiveness.No consensus on cost-effectiveness. 1: RCTs of Interventions to Improve Chronic Care Results

29 29 1: Randomized Control Trials of System Change Interventions: Diabetes Cochrane Collaborative Review and JAMA Re-review About 40 studies, mostly randomized trials.About 40 studies, mostly randomized trials. Interventions classified as decision support, delivery system design, information systems, or self- management support.Interventions classified as decision support, delivery system design, information systems, or self- management support. 19 of 20 studies that included a self-management component improved care.19 of 20 studies that included a self-management component improved care. All five studies with interventions in all four domains had positive impacts on patients.All five studies with interventions in all four domains had positive impacts on patients. Renders et al, Diabetes Care, 2001; 24:1821Renders et al, Diabetes Care, 2001; 24:1821 Bodenheimer, Wagner, Grumbach, JAMA 2002; 288:1910 Bodenheimer, Wagner, Grumbach, JAMA 2002; 288:1910

30 30 1: An Example of a Meta-analysis of Interventions to Improve Chronic Illness Includes 112 studies, most RCTs (27 asthma, 21 CHF, 33 depression, 31 diabetes).Includes 112 studies, most RCTs (27 asthma, 21 CHF, 33 depression, 31 diabetes). Interventions that contained one or more CCM elements improved clinical outcomes (RR ) and processes of care (RR ).Interventions that contained one or more CCM elements improved clinical outcomes (RR ) and processes of care (RR ). No superfluous element.No superfluous element. Didnt study interactive effects.Didnt study interactive effects. Tsai AC, Morton SC, Mangione CM, Keeler EB. Am J Manag Care Aug;11(8):

31 31 Shojania, K. G. et al. JAMA 2006;296: The Effectiveness of QI Strategies: Findings from a Recent Review of Diabetes Care

32 32 2: Studies of the Relationship between Organizational Characteristics and Quality Improvement Diabetes, preventive services, asthma, chronic disease care.Diabetes, preventive services, asthma, chronic disease care. Organizational characteristics associated with…Organizational characteristics associated with… 1.successful implementation of quality improvement programs. 2.improved health outcomes of patients.

33 33 2: Studies of the Relationship between Organizational Characteristics and Successful Implementation of QI Projects Common organizational characteristics across studies: Organized teams, including physicians, involved in quality improvementOrganized teams, including physicians, involved in quality improvement Reminder systems and patient registriesReminder systems and patient registries Reporting data to external organizationsReporting data to external organizations Formal self-management programsFormal self-management programs Others Characteristics associated with process improvement include: Receiving income, recognition, or better contracts for qualityReceiving income, recognition, or better contracts for quality Improved IT infrastructureImproved IT infrastructure Large sizeLarge size Receiving capitation paymentsReceiving capitation payments Utilizing guidelines supported by academic detailingUtilizing guidelines supported by academic detailing Primary care orientationPrimary care orientation

34 34 2: Studies of the Relationship between Organizational Characteristics and Improved Health Outcomes Similar to characteristics of organizations that successfully implement QI, those that achieve improved health outcomes are characterized by: Data reporting and feedback to physicians.Data reporting and feedback to physicians. Patient engagement and activation.Patient engagement and activation. Other common characteristics included: Computerized reminders.Computerized reminders. Involvement of organized teams, including physicians, in quality improvement.Involvement of organized teams, including physicians, in quality improvement.

35 35 3: Evaluations of the Use of CCM in Quality Improvement Largest concentration of literature.Largest concentration of literature. Includes RAND Evaluation of ICIC.Includes RAND Evaluation of ICIC. Wide variety in quality and type of evaluation design.Wide variety in quality and type of evaluation design. Majority of studies focus on diabetes.Majority of studies focus on diabetes.

36 36 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?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.Studied 51 organizations in four different collaboratives, 2132 BTS patients, 1837 controls with asthma, CHF, diabetes. Controls generally from other practices in organization.Controls generally from other practices in organization. Data included patient and staff surveys, medical record reviews.Data included patient and staff surveys, medical record reviews.

37 37 3: RAND Findings Implementation of the CCM Organizations made average of 48 changes in 5.8/6 CCM areas.Organizations made average of 48 changes in 5.8/6 CCM areas. IT received most attention, community linkages the least.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.One year later, over 75% of sites had sustained changes, and a similar number had spread to new sites or new conditions.

38 38 3: RAND Findings (2) 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.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.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 and diabetes pilot patients more likely to receive appropriate therapy. Asthma pilot patients had better QOL.Asthma pilot patients had better QOL.

39 39 3: Non-RAND Evaluations of CCM Implementation In general, those studies with greater fidelity to the CCM showed greater improvements.In general, those studies with greater fidelity to the CCM showed greater improvements. All but one showed improvement on some process measures.All but one showed improvement on some process measures. Most showed improvement on outcomes and empowerment measures, as well.Most showed improvement on outcomes and empowerment measures, as well. Sustainability and implementation of all CCM elements were challenges.Sustainability and implementation of all CCM elements were challenges. Physician and staff must be motivated to change.Physician and staff must be motivated to change.

40 40 4: Randomized Controlled Trials (RCT) of CCM-based Interventions 6 RCTs covering asthma, diabetes, bipolar disorder, comorbid depression and oncology, and multiple conditions.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.5 in the US – disease specific, 1 in Australia – multiple diseases. Practice-level randomization.Practice-level randomization. Varying levels of disease severity: mild to severely ill and highly comorbid.Varying levels of disease severity: mild to severely ill and highly comorbid.

41 41 4: RCTs of CCM-based interventions Results All but one study shows that implementation of the Chronic Care Model significantly improves process and outcome measures compared to controls and – when included in the trial – less intensive interventions (e.g. physician training alone).All but one study shows that implementation of the Chronic Care Model significantly improves process and outcome measures compared to controls and – when included in the trial – less intensive interventions (e.g. physician training alone). Often CCM implementation is linked with improved patient empowerment and education scores, as well.Often CCM implementation is linked with improved patient empowerment and education scores, as well. Active team motivation to change may be an important factor in predicting success.Active team motivation to change may be an important factor in predicting success.

42 42 5: Cost Effectiveness Studies No currently published articles evaluating the cost-effectiveness of CCM per se.No currently published articles evaluating the cost-effectiveness of CCM per se. Studies summarized on next slide examine how control of certain diseases, like diabetes, can reduce healthcare costs.Studies summarized on next slide examine how control of certain diseases, like diabetes, can reduce healthcare costs. Watch out for a new study by Beaulieu, Cutler, Ho and colleagues on The Business Case for Diabetes Management for Managed Care Organizations.Watch out for a new study by Beaulieu, Cutler, Ho and colleagues on The Business Case for Diabetes Management for Managed Care Organizations.

43 43 5: Cost Effectiveness Study Results Some evidence that improved disease control can reduce cost, especially for heart disease and uncontrolled diabetes.Some evidence that improved disease control can reduce cost, especially for heart disease and uncontrolled diabetes. Achieving cost-savings depends on the disease management strategies employed.Achieving cost-savings depends on the disease management strategies employed. Features of the healthcare market place – including displacement of payoffs in time and place and failure to pay for quality – act as barriers to a business case for quality.Features of the healthcare market place – including displacement of payoffs in time and place and failure to pay for quality – act as barriers to a business case for quality.

44 44 IV. Uses of the CCM and Next Steps

45 45 CCM Developments The Chronic Care Model serves as guide to several state programs in U.S.The Chronic Care Model serves as guide to several state programs in U.S. Adaptations of the CCM undertaken by U.K.s National Health Service, World Health Organization, and several Canadian provinces.Adaptations of the CCM undertaken by U.K.s National Health Service, World Health Organization, and several Canadian provinces. CCM foundation for NCQA and JCAHO certification for chronic disease programs.CCM foundation for NCQA and JCAHO certification for chronic disease programs. CCM part of new Models of Primary Care proposed by AAFP and ACP.CCM part of new Models of Primary Care proposed by AAFP and ACP. Several practice assessment tools now available for large and small practices.Several practice assessment tools now available for large and small practices. Assessments now used in some pay for performance programs.Assessments now used in some pay for performance programs.

46 46 Challenges Remaining Still reaching only early adopters.Still reaching only early adopters. What effective QI strategies can be offered that are less time- and resource-intensive than collaboratives? Practice redesign is very difficult in the absence of a larger, supportive system, especially for smaller practices.What effective QI strategies can be offered that are less time- and resource-intensive than collaboratives? Practice redesign is very difficult in the absence of a larger, supportive system, especially for smaller practices. How can we best help isolated small practices where majority of Americans receive their care?How can we best help isolated small practices where majority of Americans receive their care?

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