Chronic Care Model Donald Mack, MD, FAAFP, CMD Assistant Professor-Clinical Family Medicine

Objectives  Differentiate between the Chronic Care Model and the Acute Care Model  Recognize the physician roles and the responsibilities  List the elements involved in an effective chronic disease management program  Describe how health coaching facilitates self- management of chronic illness

Acute Care Model  Patient presents with a problem or complaint  Physician analyzes the problem and prescribes a solution  Follow-up is determined by the patient

Deficiencies of the Acute Care Model Rushed practitioners not following established practice guidelines Lack of care coordination Lack of active follow-up to ensure the best outcomes Patients inadequately trained to manage their illnesses 95-99% of chronic illness care is managed by the patient

Chronic Care Model (CCM) Developed in the 1990’s, by Wagner and colleagues at the MacColl Institute for Healthcare Innovation Published in 1998, “Improving Chronic Illness Care” Six essential elements

Six Essential Elements of CCM 1.the community 2.the health system 3.self-management support 4.delivery system design 5.decision support 6.clinical information systems

Video of CCM by Ed Wagner, MD, MPH (Optional additional information. Runtime 1 hour 15 minutes.) This YouTube video starts in 5 seconds Source: YouTube Channel: UNC Gillings School of Global Public Health “Improving Chronic Illness Care Across the Population”

Patient Centered Physicians know outcome goals, but telling patients what to do and motivating them to change doesn’t work... CCM has to be Patient Centered. Physicians need to ask, “What do you think will work?” “What have you tried in the past?” “What would you like to try now?”

New Physician Role “Sell” improved health behaviors Five essentials in this process are:  establish a sense of trust  uncover the patient’s actual needs  dialogue rather than monologue  don’t force “the close”  always follow up

Chronic Disease Management Concepts Patient Centered Medical Home Planned Care Model Team Enhancement Group Visits Self-management

Chronic Disease Management Concepts Patient Centered Medical Home (PCMH)  Concepts of the PCMH evolved in the early 2000’s.  In 2007, AAP, AAFP, ACP, AOA, collectively developed the Principles of the PCMH.  Focused on improving chronic illness care, transforming medical care to be more cost effective, and ensuring improved quality and efficiency.

Chronic Disease Management Concepts Planned Care Model  Evidenced-based, preventive care  Uses registries  Team assists patients to improve self- management  Proactive rather than reactive care

Chronic Disease Management Concepts Team Enhancement  Organize a team  Ensure protected, valued time  Start small and build on a success  Identify tools and resources  Reward contributions

Chronic Disease Management Concepts Group Visits  Focus on an illness with high volume, cost, or co-morbidity.  Invite patients.  Meet on a set schedule with group time to address a common issue.  Allow for some one on one time.

Chronic Disease Management Concepts Self-Management  Monitoring and making changes  Goal setting  Patient Education  Focus on day to day issues  Requires support

Health Coaching  Facilitates self-management of chronic illness  Analogy to “teach to fish” adage

Summary This module built on the information from the first module on health coaching. It introduced the chronic care model which is at the heart of the current transformation in US health care.

References 1. Bagley B. The New Model of Family Medicine: What’s In It for You. Fam Pract Manag May;12(5): Bennett HD, Coleman EA, Parry C, Bodenheimer T, Chen EH. Health Coaching for Patients with Chronic Illness. Fam Pract Manag Sep- Oct;17(5): Coleman, MT, Newton, KS. Supporting Self-management in Patients with Chronic Illness. Am Fam Physician 2005;72: Funnell M. Helping Patients Take Charge of Their Chronic Illnesses. Fam Pract Manag Mar;7(3): Lyon RK, Slawson, JG. An Organized Approach to Chronic Disease Care. Fam Pract Manag May-June;18(3): Pawar M. Five Tips for Generating Patient Satisfaction and Compliance. Fam Pract Manag Jun;12(6): Wagner EH. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Eff Clin Pract Aug-Sep;1(1):2-4.

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